De-risking care transitions by distilling signal from noise

Transitions of care are a huge pain point for healthcare organizations. This is especially true for high-risk, often elderly patients who frequently move between different medical facilities and levels of care.

As the journal Health Affairs noted in a 2012 report, inadequate care coordination, including inadequate management of care transitions, was responsible for an estimated $25 to $45 billion in wasteful spending in 2011. More recently, in 2015, CMS reported that nearly one in five Medicare patients discharged from a hospital are readmitted within 30 days, at a cost of more than $26 billion every year.

Data like these underscore the need to focus on improving transitions — but the remedy isn’t always so simple. Detecting high-risk patients, or those that may be more likely to return to the hospital, involves multiple moving parts and healthcare organizations involved in caring for each patient. This makes life even more challenging for Accountable Care Organizations (ACOs) and similar risk-bearing organizations. If care is even slightly fragmented — for example, a care partner such as a skilled nursing facility (SNF) cannot share information through an EHR — a patient may be transitioned improperly and suffer dire consequences.

Zeroing in on care transfers can only benefit patients and caregivers. It will lead to better outcomes for patients, and save both healthcare organizations and the greater health system money. And since CMS is now regularly penalizing hospitals for readmissions as part of its Hospital Readmissions Reduction program, the extent to which a healthcare provider keeps patients avoidably out of the hospital has a direct impact on an organization’s bottom line.

However, to improve transitions, healthcare organizations also need better information at the point of care, during the critical moments when the decision on how and when to transfer patients between settings is made. The transitive care moment is a key opportunity and risk area for outcomes. Better information leads to better decisions, and ensures fewer patients fall through the cracks.

Understanding Transitional Issues

There is no one singular cause of poor care transitions. Patients who are at highest risk for suffering the consequences of a bad transition are complex, with multiple chronic conditions and the need for many resources. Whether they reside in their home, assisted living facility, or nursing home, the patients at the highest risk of rehospitalization or other adverse events are often seen by multiple specialists, and may rely on community programs such as Meals on Wheels. Even then, they don’t always have an adequate support system in place to ensure their other needs — such as medication management, wound care, or transportation assistance — are regularly addressed.

Initiatives such as CMS’ Chronic Care Management (CCM) Program, established in 2015, have sought to address post-transition for patients with chronic health diagnoses. The CCM program offers financial incentives for physician practices overseeing care of these patients, in and out of the exam room. Program participants often report more engaged patients, who are more compliant with healthcare and medication protocols, and more inclined to self-report medical issues (e.g., a spike in blood sugar or weight gain).

Yet programs like CCM largely help after a transfer is made. If a patient is discharged improperly in the first place, a program such as CCM may not be enough to prevent an adverse event from occurring.

For example, if an elderly patient who has fallen shows up in the hospital with a broken leg, the emergency department is immediately alerted to the acute issue — in this case, the broken leg — while other potential issues (such as the patient’s frequent visits to other ERs) may be overlooked. At a macro level, the broken leg is much less important than the patient’s underlying opioid addiction or high-risk environment. If that patient is offered a prescription for narcotic painkillers upon discharge, they could be back in the hospital when the prescription runs out.

One might ask, how would a hospital or other health facility miss these details? In addition to being slammed on a minute-by-minute basis, inundated with nonessential alerts and an onslaught of patients, clinicians don’t always have access to the most up to date information.

Consider skilled nursing facilities (SNFs), where many high-risk and elderly patients reside. A 2016 ONC data brief noted that EHR adoption lags in SNFs due, in part, to their ineligibility to receive financial incentives to adopt them by CMS (the brief also noted that just three out of 10 SNFs electronically exchange key health information). Also, the more recent Medicare Access and CHIP Reauthorization Act (MACRA) lacks incentives for care providers who deal with patients who need long-term or end-of-life care.

Given these realities, it’s easy to see how a lack of a technology that allows organizations to share data can lead to fragmentation in care, and how fragmentation ultimately puts the patient at risk.

Creating Better Transitions

The patient medical records of a high-risk, chronic-needs individual could be compared to classic literature: dense and engrossing, full of details that are rich but raise questions. It takes a bit of stepping back, and considering the full context, before the most important themes and ideas can be extracted.

The right notification tools can speed up this process, extracting the most meaningful information, and presenting it in an easily digestible format, like CliffNotes, at the point of care. In other words, the right tools can cut through the noise, pulling nuggets of information that would otherwise drown in a sea of data.

To illustrate how the right, modern-day care coordination tool would work, let’s consider another hypothetical patient — Mr. Smith, a 67-year-old man with CHF, hypertension and diabetes who only receives weekly visits from a part-time home health aide. One day, a flare-up of his CHF lands him into the ER. Within 20 minutes, a nurse administers medication to stabilize his condition. As his symptoms subside, the hospital case manager prepares him for discharge.

However, if the case manager isn’t aware that Mr. Smith visited the ER multiple times in the prior six months, she may not be alerted to his lifestyle hazards, such as an absentee caregiver, his history of medication noncompliance, or his dependence on Xanax originally prescribed for a sleep disorder. Were Mr. Smith’s care team aware of these facts, they would potentially transfer him into a more suitable long-term care setting such as a skilled nursing facility, which could better manage his condition and keep him out of the ER indefinitely.

The sooner Mr. Smith’s care team is aware of his greatest health and lifestyle challenges, the sooner they can offer appropriate interventions. When Mr. Smith’s health steadily improves, the health system saves thousands of dollars.

While no single tool or communication strategy can keep every patient out of the hospital, or guarantee a perfect transition of care, the more key insights we have into patients at the point of care, the better able we are to allocate limited resources. When organizations can effectively share information, and have more shared visibility into some of the “red flag” issues that impact transitions of care, everyone wins.

Benjamin Zaniello, MD, MPH, is a practicing physician and the chief medical officer at Collective Medical. Collective Medical has built the nation’s largest network for care collaboration.

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