The key to streamlined care transitions? Interfacility relationships, according to 2 health IT experts


Only 16 percent of acute care providers report sharing all patient data with other care facilities, meaning key elements critical to care coordination are often missing from interfacility exchanges, according to a recent study by PointClickCare.

The study also found that providers most often rely on manual hand-offs, email and fax to share patient information, with just 11 percent of acute care providers using an integrated EHR. The results reveal that for a lot of providers, exchanging health data and coordinating care is still an uphill battle.

"By giving stakeholders the ability to access and exchange insights through a secure, single source, the result is faster, more confident decision-making, resulting in smoother transitions of care," said Sean Vandeweerd, a senior product manager in care coordination and post-acute insights at PointClickCare.

Here, Mr. Vandeweerd and B.J. Boyle, vice president and general manager of post-acute insights at PointClickCare, speak to Becker's Hospital Review about the components of an effective data-sharing system, and how such technology can enable strong interfacility partnerships.

Editor's note: Responses have been lightly edited for length and clarity.

Question: How can technology help both hospitals and skilled nursing facilities avoid obstacles to smooth transitions of care and reduce readmissions?

B.J. Boyle: As value-based care and other emerging reimbursement models gain prominence, hospitals are no longer approaching these transitions as a simple change of venue — they're becoming more coordinated. They need technology to help scale those efforts and an empowered team to monitor the scaling process using tools such as communication and care coordination platforms.

The second part is easing the exchange of meaningful data. A lot has been said about interoperability and data sharing, but not enough attention is paid to ensuring that shared, standardized data is driving behavior or outcomes. Long-term care facilities need systems that allow them to receive and process information, which will not only speed medication reconciliation and admissions, but also allow facilities to better determine proper care pathways.

Sean Vandeweerd: Traditionally, each point-to-point connection between facilities might take up to six months. Today, a lot of these problems can be solved using scalable infrastructure. The solutions already exist: There is a whole range of tools that make interoperability and data exchange a lot easier for facilities looking to work together. The industry is just now starting to adopt some of these solutions.

BJB: A lot of vendors each have the tools to solve one piece of the problem, but the technology needs to seamlessly connect acute to post-acute care. In the future, it's not going to be good enough to only be notified when a patient has left one facility and been admitted to another, with an entirely separate reporting system compiling performance metrics about a skilled nursing provider. Instead, connected care management systems will allow the data to flow from one system to the next and provide a continuous view of what's going on at the patient level — rather than having to pull up seven different programs to follow one patient's path.

Q: What are the most important characteristics of an effective data-sharing infrastructure?

SV: The first, most basic element is making sure there are shared objectives at the start of the process. The second is a common language around the information, data or other contexts being shared. Third is scalability. 

Each hospital and facility is unique, and being able to establish a common language, as well as the technical infrastructure, allows you to build connections that go beyond just the simplest dataset and to scale out 100 hospitals to 1,000 nursing facilities or 1,000 assisted living facilities. You need to be able to go both deep, in terms of the data being sent, as well as wide, in terms of how many facilities can be connected across a network.

Q: What kinds of performance data on skilled nursing facilities should hospitals be looking for when making referral decisions?

BJB: Ultimately, a referral decision comes down to the patient. Many seniors, in particular, suffer from multiple comorbidities, so hospitals must look at the whole patient to understand the whole partner.

At a macro level, though, performance data must cover the entire spectrum; hospitals need to look at skilled nursing facilities as holistic providers. Broad-level public metrics like CMS's Five-Star Rating can be helpful, but it's also important to understand how potential partners are performing in the context of specific disease states: What's their admission rate by disease state; what's their average length of stay?

Q: How can hospitals leverage technology to gather that performance data?

BJB: One of the most important considerations is the timeliness of data. Publicly available data about post-acute facilities or data collected via claim sites is often several months out of date. The ideal technology provider, then, will provide facility-level metrics and help hospitals understand how they can manage the performance of those partners.

An even more critical consideration is transparency of post-referral patient data. That's where it becomes crucial to have technology that provides a truly connected care management system, giving a unified view of how the patients are doing in the post-acute facility. It's important to look at data not just at a facility level, but also patient by patient.

SV: Rather than relying on the traditional model of clunky and time-consuming retroactive analysis of performance data, technology can now take care of everything. Managers within preferred provider networks, long-term care facilities or hospitals can use technology to standardize and synthesize data all the way from a high-level view of a condition-specific metric like readmission down to a detailed view of the individual patient events that caused any negative outcomes to occur. This not only gives providers a better idea of the drivers of adverse outcomes but does so in real time.

Q: More generally, how can hospitals leverage technology to make better referrals and recommendations overall?

SV: One way is by better understanding the real data in real time. Being able to leverage analytics and information that help direct referrals to the most ideal facilities will lead to better outcomes than traditional methods focused on simply completing care transitions as quickly as possible.

That data also needs to be as complete as possible. Referrals are an extremely hectic time, and facilities that respond to referrals or work with hospitals to place patients often have incomplete information, which can result in a patient being placed in a facility unable to accommodate their needs. Information needs to move bidirectionally within the system.

BJB: And it isn't always about technology; the referral has to stem from partnership. We encourage hospitals to look at referrals not just as shunting patients along to the next line of service, but as an opportunity to form relationships. Hospitals and acute providers must recognize that working together creates a seamless continuity of care and, ultimately, reduces readmissions and improves outcomes.


PointClickCare's Patient Transition Study, conducted in partnership with Definitive Healthcare, highlights the ways providers can enable smooth transitions of care by leveraging sophisticated data-sharing solutions. C-level executives from acute and post-acute care facilities provided input on data sharing, concerns about interoperability and other pressing pain points in care delivery and coordination in the blinded, voice-of-customer quantitative study, which contains valuable insights for providers looking to improve care transitions and reduce readmissions.

Learn more here.



© Copyright ASC COMMUNICATIONS 2021. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.


Featured Whitepapers

Featured Webinars