Transitions of care are no longer a simple hand-off: 2 health IT experts explain how to enable cross-continuum care coordination

When a provider is determining the most appropriate post-acute care facility for a patient, they examine a variety of factors, including location, interfacility relationships and, most importantly, patient and family choice — all of which are driven at the core by performance data.

"As families become used to having more data at their fingertips, they're going to want to make data-driven decisions about placements," said B.J. Boyle, vice president and general manager of post-acute insights at PointClickCare.

As a result, he explained, while acute care providers must have a cohesive data-sharing infrastructure in place in order to provide necessary information to patients and their families, post-acute providers also face greater scrutiny and must be able to adequately articulate their strengths to both patients and potential provider partners.

Here, Mr. Boyle and Sean Vandeweerd, a senior product manager in care coordination and insights at PointClickCare, discuss with Becker's Hospital Review the factors that play into a referral decision and explain why that decision is not the end of the care transition.

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

Question: What roles in a hospital are responsible for determining a post-acute care setting for a patient?

B.J. Boyle: Traditionally, the predominant model has been that the physician who makes discharge orders works with titles such as the discharge planner or placement manager. These managers identify skilled nursing facilities within a patient's community that may be able to accept that patient and work closely with the family to determine which facility will be the most convenient and fit best with the patient's lifestyle.

But we're starting to see a bit of an evolution here. Preserving family and patient choice is still critically important, but a number of health systems are forming networks of post-acute providers who will act as their strategic partners. While they certainly preserve family choice, these partners are built to be a provider's main referral source and ensure patients are referred to high-performing facilities that have already been vetted.

Q: What impact do those preferred provider networks have on referral decisions?

Sean Vandeweerd: Often, when a hospital or an accountable care organization is looking to improve patient care and manage costs, one of the first steps is to make sure they're sending patients to the right partner facilities. For example, rather than referring to 100 facilities they might reduce that number to somewhere between 30 or 60 facilities, based on aggregate performance metrics such as readmission rates and length of stay.

These networks can greatly affect facilities by reducing or increasing referrals based on performance data: They might go from receiving 30 percent of their patients from a single hospital down to just 5 or 10 percent, while another facility might grow to receive 80 or 85 percent of its referrals from that same hospital.

One of the things we talk about a lot is being able to build high-performing networks, rather than narrow networks — going deeper than just looking at a months-old readmission rate to focus instead on building a network of the best providers for your specific patients. That entails looking into clinically focused data: not just readmission rate, but readmission rate for a particular patient's condition, going beyond looking at the number of patients who are sent back to the hospital for that condition to examine how a facility is able to best care for those patients.

BJB: In a study published about a year ago, about two-thirds of all the hospitals surveyed reported that they were narrowing their networks. About 90 percent of those said they were doing so by collecting data on their skilled nursing facility partners. More and more, providers are looking outside their communities and digging deeper to find the best possible partners for their networks.

They're collecting data, they're hiring staff to work out in their communities and they're looking at narrowing their networks, but, for the sake of both technology providers and post-acute providers, we have to make sure that narrowing networks isn't just happening to happen. We have to make sure it's happening for the right reasons and driving the right outcomes.

Q: How much of an impact do other historical or existing relationships have on referral decisions?

BJB: There are two ways to look at this. Obviously, longstanding business relationships between a hospital and skilled nursing providers are important, but today, proven results have become more important than those relationships. Ten years ago, it used to be about buying lunches and building a network of relationships, but now, it's really about results.

We recently watched one of our partners go through and change some members of their network, and it all based on performance: Were they able to meet the contract, with results driven by the availability of data? We don't want to devalue relationships, but it's easier now to look beyond those at actual performance data, which is a more direct driver of value-based care.


Q: How much of an impact does geography have on referral decisions?

BJB: Location is obviously really important. In more populated, urban areas with more facilities, location is still one of the main drivers, but outcomes are becoming increasingly important: what level a facility is, how they perform, whether they offer the right services.

Q: What about in areas where there aren't as many facilities?


SV: We've spent a good amount of time working with facilities and hospitals that aren't in major population centers, and there, location matters because it's generally not good for a patient to spend hours and hours in transport after a recent cardiac event, for example. Even in rural areas, while you're not necessarily going to have the same type of aggressively built-out preferred provider networks as you would in an urban area, location still plays a role in that you want to make sure each patient is in the right location that can provide the best care for their specific condition.

That said, you don't want to send them to just any facility. Increasingly, even in places with smaller populations, ACOs and hospitals are driving referrals and helping families better understand what the right facility is for their family member and their specific condition.

Q: Anything final thoughts?

BJB: For a long time, referral decisions have represented a hand-off, but that notion is beginning to disappear; now, post-discharge, a patient is still partially the original provider's responsibility. Case managers are showing up at skilled nursing facilities to monitor care pathways and look at how they share responsibilities with a provider.

We need to think beyond simply optimizing the care transition and begin to think more about enabling that "cross care." To do that, you need to make sure you have technology partners that can drive a seamless workflow, allowing you to leverage a standard analytics system to monitor how patients are doing, regardless of where they're receiving care.

In the future, transitions of care will grow well beyond the referral. We'll see providers putting the patient at the center of the process and thinking not just about their discharge and transition, but following them through their entire episode.


The recently published Patient Transition Study from PointClickCare and Definitive Healthcare demonstrates how data-sharing solutions can enable smooth transitions of care. The blinded, voice-of-customer quantitative study's findings were drawn from the input of executives from acute and post-acute care facilities on data sharing, interoperability and other pain points in care delivery and coordination. As a result, the study contains valuable insights for providers looking to improve the transition of care process and reduce readmissions.

Learn more here.

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