See the technology that is making care transitions better


Several technology vendors tout solutions that better link provider and patient while lowering dreaded readmissions.

Technology has created a new era of care transition that is empowering the post-acute sector while creating a shared sense of responsibility when it comes to the ultimate care of the patient.

But although care transition has been a focus for years, it has gained greater prominence due to recent pressures of readmission penalties and prospective payment models that require providers to assume more risk, said Tom Sullivan, MD, chief strategic officer for Rockville, Maryland-based DrFirst.

"The big risk for errors is from acute care to where the patient goes next – rehab, home or nursing home," Sullivan said. "Discharge plans are so complex now, but if they aren't followed closely, the patient will get readmitted, and now there are penalties. If you don't get the transition right and the readmission could have been avoided, it will cost the system more money."

Information technology is enabling providers at each care site to receive, evaluate, monitor, and, yes, nag patients to promote their health and safety. But minding the patient's health status remotely through various tech is key to preventing costly hospital readmissions, industry analysts say.

DrFirst is contributing to the care transitions process by taking advantage of the nearly universal move to mobile solutions. Its Backline product allows for chat via text or voice and includes a patient-centered chat function as well. Because the Office of the National Coordinator for Health IT has called for test and lab results in addition to an exchange of summaries, the DrFirst tool uses the mobile platform to enable exchanges beyond the desktop, Sullivan said.

One major challenge in maintaining the continuity of care during a patient transition is smoothing over the gaps where patients can fall through, said Nan Hou, RN, managing editor for Los Angeles-based Zynx Health.

"The most common gap between acute and post-acute care is hospital-to-home," Hou said. "The main problem is communication between the transferring provider and receiving provider – one-third of them don't receive documents from the hospital and only 12 percent to 34 percent of discharge summaries reach the care teams."

CMS and other organizations have developed performance measures for care transitions through various initiatives, such as: Project RED (Re-Engineered Discharge), Boston University; Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine; IHI STAAR Initiative (State Action on Avoidable Rehospitalizations); IMPACT (Improving Massachusetts Post-Acute Care Transfers); National Transitions of Care Coalition's "Transitions of Care Measures"; National Quality Forum: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination; and University of Pennsylvania Transitional Care Model.

The collective effort is to produce evidence-based guidelines for transition management, Hou said.

"Effective transition care management has a triple aim – quality of care, patient satisfaction and lower costs," she said. "Evidence-based guidelines can help providers leverage best practices by identifying problematic areas like communication and factors that contribute to the gaps."

Compliance is key

Al Kinel, president of Rochester, New York-based Strategic Interests, said there are eight types of transitions of care: Hospital-to-home, hospital-to-long-term care/post-acute care provider, LTPAC provider-to-home, patient-centered medical home-to-primary care provider, home-to-hospital, LTPAC provider-to-hospital and hospital-to-hospital.

But of the eight transitions of care that exist, the one that nobody wants is from the post-acute sector back to the acute care environment, otherwise known as the dreaded hospital readmission. Medicare is issuing penalties because transitioning in the wrong direction is a principal reason for higher healthcare costs. Hospitals may feel the immediate sting of a readmission penalty, but the process takes its toll across the continuum.

The easiest care transition is to ensuring that patients comply with physician orders – especially for patients with chronic conditions like diabetes, COPD and CHF. With its history in call centers and acquisitions of 30 communications technology companies, Omaha, Nebraska-based West Corp. hopes to provide a continuity that better enables transitions of care.

Patient noncompliance has taken a tremendous financial toll on the pharmaceutical industry, costing drug manufacturers about $637 billion in revenue each year, according to Orlando, Florida-based AssistRx. The nonadherence results in roughly 125,000 preventable deaths and up to 69 percent of medication-related hospital admissions annually.