Electronic Health Reporter

By Lee Horner, CEO, Synzi.

Care transitions, such as pre- and post-admissions and pre- and post-surgery, are pivotal points for ensuring adherence to the care plan and improved outcomes. However, organizations have historically struggled to keep patient engaged and compliant with the care plan during these transitions – leading to costly re-admissions and poor satisfaction. Virtual care can be applied in these settings to provide an efficient and convenient way to keep the lines of communication open during these pivotal transitions, leading to increased adherence and better outcomes.

Importance of transitional care

A carefully considered transition of care strategy is critical to enabling the safe and timely movement of patients throughout the care continuum. Each transition stage should include the communication of a comprehensive care plan that ensures continuity and coordination of care across points and providers of care. Points of care include hospitals, rehab centers, skilled nursing facilities, long-term care facilities, and even the patient’s own home. Providers of care include clinicians, specialists, nurses, home health workers, in addition to pharmacists, nutritionists, interpreters and transportation assistants.

According to the Joint Commission Center for Transforming Healthcare, sub-standard transitions may result in delay of treatment, inappropriate treatment, adverse events, omission of care, increased hospital length of stay, avoidable readmissions, increased costs, inefficiency from rework and other minor or major patient harm. According to JAMA, failures of care coordination can increase costs by $25 billion to $45 billion annually.

Obstacles to a successful transition of care

Insufficient or unclear communication across points and providers of care may impact a smooth care transition. Academic Medicine estimated that 80 percent of serious medical errors stem from miscommunication during the hand-off between providers. Relating to miscommunication, the Center for Transforming Healthcare’s hand-off communication project highlighted the following risk factors:

• Senders and receivers of the patient may have different expectations as to what happens next
• The hand-off may be rushed; the providers involved might not be sure of everyone’s role and responsibility before, during, and after each transition
• Standardized hand-off procedures are not in place; a clear process has not been documented and discussed with all settings and providers

Before the patient has left any facility, a plan for the patient to access convenient follow-up care needs to be in place to ensure that the patient remains supported, even when the patient is being transferred to another setting or home.  

Role of a virtual care communication platform
Better patient-centric care can be facilitated if critical information and appropriate expectations are shared with all care team members as well as the patient and his/her personal caregivers in advance of each transition. With a virtual care communication platform, providers and patients can communicate before, during, and after each transfer.

Before the transfer, all involved can participate in a video-based virtual meeting to align on the next steps for the patient. The patient can be “introduced” to his/her core provider at the next setting, thus alleviating any anxiety about who will be responsible for his/her care. During the transfer, remote family members and personal caregivers can “check in” and see how the patient is handling any potential stress involved with movement across facilities and providers.

Care team members can quickly reach out to their counterparts if there are delays or unexpected issues when transferring the patient to another facility or home. After the transfer, the broader care team– specialists, care/case managers, pharmacists, visiting nurses, nutritionists, interpreters, and transportation assistants – can continue to use video, emails, texts and SMS messaging to discuss the patient’s progress and potential upcoming transfers. The provider can use the platform to monitor and motivate patients – even after the patient is residing in another setting or has returned home.  Ongoing check-ins are especially needed in the first 30 days post-discharge in order to minimize the risk of costly and unnecessary re-admissions.

As patients move between levels of care, across care settings, and amongst care providers, a virtual care communication platform can ensure that each transfer is well-planned and well-executed. The goal of any transfer is to maintain the continuity of care without subjecting the patient to greater risk for stress, infection, or other adverse events. A clear and concise plan for the transitional care can minimize errors and omissions, better align the sending and the receiving providers on next steps, and enhance the patient’s overall care, safety and satisfaction.