Tech-driven care transitions

In 2010, at the beginning of the Meaningful Use (MU) program, participating providers gave patients clinical summaries, which were designed to engage patients as they moved through the healthcare system. The summary provided patients with specific directions for their care, such as managing medications, scheduling referrals and self-care.

Although the MU program aimed to increase patient engagement and care coordination, many providers did just enough to check the boxes to meet the thresholds. Providers and staff were satisfied with maintaining the status quo of faxing and continuously chasing down documentation, despite the Health Information Exchange (HIE) MU measure, which was intended to encourage providers to send patient health information electronically in transition-of-care scenarios.

As healthcare providers and organizations advance their use of health IT and HIE, a comprehensive Summary of Care discharge record must be considered as a valuable patient navigator. Many patients may not have the means to comprehend or retain discharge information, and family and friends may not remember or understand, either.  A clearly documented discharge plan helps get the appropriate information from point A to point B and can have a significant impact on the value of post-acute care. We need to treat transition of care documentation as a reliable technical patient navigator.

While working on a project to implement and improve the use of HIE in care transition settings, I received the following summary of a preventable hospital readmission. This 2016 example demonstrates the need for consistent navigation during the process of discharging to post-acute care. The case came from a visiting nurse assistant (VNA) who was involved with a patient’s discharge from a hospital:

• Day 1—VNA received referral from hospital following patient hospitalization for elevated liver enzymes and acute renal failure. Anticipated discharge on Day 3. Skilled nursing services, physical therapy and occupational therapy ordered.
• Day 4—Patient admitted to skilled nursing services (SN). Discharge orders for diet: low-sodium diet.
• Day 5—SN has orders to draw a Complete Metabolic Panel, but is unable to do so. SN notes that patient very dehydrated. SN instructs patient to drink fluids.
• Day 6—SN visit to re-attempt blood work. Patient very short of breath. O₂ saturation down to 85 percent. Low blood pressure and dizzy. 911 called. Patient transported back to hospital.
• Day 7—Patient admitted for fluid overload. Hospital nurse from floor upset with SN because patient was supposed to be on a 1,000 ml fluid restriction. Nurse says extensive teaching was done with the patient in the hospital. No mention in any discharge paperwork for fluid restriction nor was the restriction communicated to VNA. VNA clinical director set up conference call with case management director to discuss case. Fluid restriction was not noted in any of the paperwork.
• Day 14—Patient readmitted back to VNA with 1,000 ml fluid restriction.

In the above case, the communication and documentation for both the patient and providers was clearly deficient. Although plenty of technical tools are available for consistent messaging in care transitions, the benefits of the tools are not often used to their full potential.

Providers use multiple navigation tools to engage patients at discharge, such as pictographs, patient portals and/or technical, sometimes confusing, documentation. In the VNA case, the hospital floor nurse claimed extensive education was provided to the patient on restricting fluids during discharge. However, there was no written documentation in the discharge summary of care, and the patient did not understand or remember to limit fluids. Hence, consistent patient navigation tools for both patients and providers must be a priority as they travel to a post-acute setting.

With the shift to value-based care, post-acute services are becoming an integral part of many healthcare programs. The Hospital Readmissions Reduction Program, IMPACT Act, Meaningful Use Stage 3 and the Quality Payment Program (QPP) are all examining the critical nature of transitions of care. These programs can potentially assist in placing health IT at the forefront of sharing healthcare information.

In reviewing the 2015 Edition Health IT Certification Criteria, the electronic health record (EHR) certification categories are clearly aimed at expanding health IT in a variety of care settings, including post-acute care. Categories include electronic exchange, care coordination and Health IT design and performance.

Discharge information must clearly address patient’s needs and treatments, identify all necessary care services and reduce readmission factors. With the new certification standards, the focus is on supporting the advanced use of EHR technology. Providers caring for the same patient are sharing information. The goal is to create a common clinical dataset and foster the navigation and reconciliation of data among HIT pathways. This is all designed to contribute to a better, safer navigation pathway for patients.

As of 2016, more than 90 percent of large, medium, small, rural, and critical access hospitals were meaningfully using certified health IT. But the technical capabilities of certified EHR technology (CEHRT) within these hospitals go widely unused. The value-based initiatives are a call to action. Hospitals need to expand their use of EHR technology and work with their EHR vendors to implement certification. At the same time, post-acute facilities must work closely with the hospitals on HIE and take the time to begin, continue and align their own HIT initiatives.

Although the timeline for 2015 CEHRT implementation varies across EHR vendors, the next two years will inevitably lead to more advanced HIT and HIE capabilities. Post-acute facilities must commit the time to analyze their own HIT needs. To begin this process, post-acute organizations without a certified EHR should:

• Vet a HIT selection process.
• Involve all necessary team members in the selection process.
• Collaborate with care provider trading partners.

This commitment can assist facilities in implementing an efficient EHR system to share patient data consistently, collaboratively and electronically.

For those who have implemented EHRs already, now is the time to work with EHR vendors on care transition technology and capabilities. Post-acute organizations that fall into this category should:

• Study the content and performance of the EHR.
• Examine the data exchange functionality and care plan documentation within the EHR.
• Initiate HIE conversations with the appropriate clinical and technical staff at hospitals.
• Start testing the information exchange capabilities with hospitals during discharges and keep the conversations going.

The goal is to create and use patient navigation tools consistently across all trading partners including hospitals, primary care providers and post-acute care services as transitions of care are taking place. Having the correct medication list, identifying and clearly listing the post-acute provider(s) who are responsible for ongoing care, identifying those who can sign orders and having the proper instructions post-discharge can ensure a safe and effective discharge and ultimately reduce preventable readmissions.

Nancy Fennell is a Senior Practice Consultant with Massachusetts eHealth Collaborative.

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