Failing transitions

Mary didn’t receive instructions on her mother, Eartha’s, medications after a hospital stay.

After a medication that was supposed to be short term was given to Eartha long term, she suffered irreversible kidney damage. Mary was then given the choice to put her 82-year-old mother on dialysis or take her home on hospice.1

The effectiveness and quality of providing care is built on strong foundation of education, communication and collaboration.

Readmissions in the United States have been associated with about $41.3 billion per year on hospital costs according to briefs by the Agency for Healthcare Research and Quality. When a failed transition occurs the patient experiences diminished medication adherence, appointment and treatment compliance failures and little to no transparency over information that could result in early preventative care measures. Combined, these issues create a wide-scale medical crises and increased healthcare costs to healthcare providers, patients and insurers that are often preventable.

As care complexity and acuity increases it is vital that all participants across each patient’s healthcare team must be invested, connected and collaborating to stop the continued growth of costly and life threatening failures in Care Transitions.

According to JAMA Internal Medicine in 2016, healthcare miscommunications contribute to a quarter of readmissions. Unfortunately, the widespread use of different technologies and coordination missteps by providers has only increased disconnect between patients and communication of real-time information involved in care.

Too often, the care-network gaps lead to the disappearance of the care recipient during transitions.

Care teams utilizing dynamic, connected care circles to provide ongoing education, support and care oversight are proving to be a fundamental requirement to reduce healthcare costs and support successful patient outcomes.

Caregivers, families, community support (Meal on Wheels), and the care recipient must be able to communicate efficiently, securely, and in real-time to ensure the continuity of care and most cost-effective transitions are maintained.

“Patient access to health data also helps providers do their jobs. When patients view their data on the patient portal, they learn more about their conditions and are better equipped with questions and discussion points prior to doctor’s appointments.”

Patient-centric connectivity across all physicians, to home health agencies, family and community support provides the patient with peace of mind that everyone in their healthcare team is always on the same page and receiving the information they need to provide the best and earliest care possible.

Early this year American Geriatrics Society released metaanalysis of discharge planning interventions with caregiver integration and found that education of patients and their families prior to discharge utilizing a variety of methods is associated with 25% readmissions at 90 days and 24% fewer readmissions at 180 days. Patient engagement beyond the facility doors is essential to continuing education that was begun as an inpatient regarding diagnosis, prognosis and treatment.

Medication non-adherence alone is now adding around $290 billion each year to overall U.S. health spending as reported by National Community Pharmacists Association. Access to the right information, at the right time, regardless of location will facilitate successful care transitions. All movement towards a seamless transition will increase the care co-efficient of health and wellness of the care recipient, connectivity and communication between caregivers and family and ultimately reduction of readmissions and healthcare related costs.

Providing a tapered transition using Care Technology to provide education enables healthcare organizations to meet the patient and family’s ongoing needs wherever they are culturally, socially, geographically, and with content that is appropriate for wherever they are on the health literacy spectrum.

Involving Family: The Caregiver Advise, Record and Enable Act
35 states have independently begun recognizing the importance of transparency and managed transitions of care to home by passing the Caregiver Advise, Record and Enable (C.A.R.E) Act. This law states that, prior to being sent home, a healthcare facility must:

1. Record the name of the family caregiver when a loved one enters the hospital.
2. Notify the family caregiver prior to the loved one’s discharge.
3. Provide the family caregiver simple instruction of the medical tasks they will be performing when their loved one returns home — like managing medication.

Non-medical loved ones, friends and family members are taught the information and skills needed to ensure a thorough understanding of the patient’s diagnosis, prognosis and appropriate treatments and follow up needed. Rather than relying on the family to know what to ask or to actively seek out information that they may not know they need to have prior to discharge, these laws out the burden of education and training back onto medical professionals and hospitals systems who have a vested interest in creating the best possible outcome for all patients.

Care-in-place and Age-in-place will continue to be the preferred and less costly of care scenarios and technology now provides the ability for all involved to be collaborative (as appropriate) in the care circles and follow the recipient across their care related journey.

Regardless of tech-sophistication, the care recipient can be securely connected and sharing daily activities, care related tasks and stay in touch with caregivers and family members. Today’s CareTech enables transitions to be fluid and seamless while providing the data and real-time information needed across traditional and digital healthcare devices and scenarios. Interdependence provides the safety net for care transitions.

Call To Action
Utilizing Care Tech that meets the patient and family’s health care needs by providing timely and accurate education, collaboration and communication tools wherever they are, across multiple disciplines and regardless of acuity or complexity benefits both the care organization and the patient by improving their outcomes post treatment.

About the Authors
Melissa Trevino – Client Engagement Manager - LifeAssist Technologies. You can reach her at
Hjalmer Danielson – Is Head of Marketing - LifeAssist Technologies, enables ongoing connections for secure, transitional care that bridges silos between people and data. You can reach him at

1 AARP, NC should join the 35 states, DC and territories that help transition loved ones from the hospital to their homes, 2017 -

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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