A Patient’s Perspective on Improving Care Transitions

October 25th, 2011 by DCPatient Leave a reply »

Two recent speaking engagements provided me the opportunity to think deeply about the discharge process, an area of healthcare delivery rampant with errors and missed opportunities to support sustained healing and health for patients. This is an area of keen interest to me as I have experienced the discharge/transition process 16 times ( I may have lost count in there somewhere) as a patient and twice as a caregiver to spouse and parent.

On October 20th I delivered Grand Rounds at Montgomery General Hospital. My topic was Patients as Partners in Quality Care Improvement.

On October 13th I had the privilege of being the patient speaker at an event focused on identifying opportunities for technology to improve the transition of patients from acute care settings to home or a rehabilitation or long term care facility.  “Putting the IT in TransITions” was convened by the Office of the National Coordinator for HIT as well as the John A. Hartford Foundation and the Gordon and Betty Moore Foundation in Washington, DC at the Kaiser Permanente Center for Total Health.

The three questions posed were:

1. What are the most important problem statements from the patient’s and caregiver’s perspective that require our attention?

2. Where is IT effectively addressing these challenges now?

3. Where is innovation most needed now?

The invited attendees participated in breakout sessions to brainstorm on the four particular areas of transition:

1. Discharge process

2. Medication reconciliation

3. Information flow and feedback

4. Patient and care-giver activation


Below are some of the key points from my presentation.  The entire webcast can be seen at http://www.visualwebcaster.com/event.asp?id=82572.  (I start at minute 42)

Successful discharge begins at or before admission.

Reducing readmission is based on addressing the totality of the circumstances that a patient encounters when they leave the hospital.

Opportunity 1: Accurate electronic transmission and appropriate exchange of a patient’s medical history, including known allergies and other alerts can aid and speed diagnosis, avoid unnecessary tests and scans, avoid repeating failed treatments, and laser focus on will work. [Tech Op:  Portable Patient Health Record]

Opportunity 2: Sharing information, including lab values, with patients and caregivers in real time creates trust, and leverages the ability of patients and families to spot errors and omissions.  An EMR is only as good as the information is used. [Tech Op:  EMR]

Opportunity 3: Coordinating, accelerating the integration and conflict resolution of information across specialists is an essential HIT function that power to truly impact care and bend the cost curve in the management of complex patients.  As a liver transplant recipient for underlying autoimmune conditions that manifest in GI and other areas I need to get sign off from all groups before discharge.  This has often taken a full days worth of nurse-hours to procure. [Tech Op: EMR]

Opportunity 4: Beginning the education process – nutrition, self-care, new medication regimens – long before the discharge day would provide an opportunity for patients to begin formulating questions for medical staff in a more timely fashion and start the process of strategizing how to adhere. [Tech Op: Ipads loaded with videos, links to Medline, patient disease state communities]

Opportunity 5: Customized, tailored discharge plans can be populated and continuously updated throughout the hospital stay, triggering communications to long term stay or rehabilitation facilities for certain conditions, orders for medications, equipment, even groceries that meet a prescribed dietary change.  Everything a patient needs to do or have for the immediate post-discharge period needs to be ordered, arranged, scheduled and delivered before they leave the hospital. No exceptions.  Patients are sick, tired, happy to finally be home.  Caregivers and sick, tired, happy to finally be home.  They may not be able to leave the patient to run between pharmacy, grocery store, medical supply once they get home.  Follow up calls to physicians and often not made in the return to home life.  Let’s say good bye to the scribbled sheet of paper with vague generic instructions hastily put together in the final hours of a stay.  [Tech Op: E-prescribing, Peapod/Safeway grocery delivery, RHIE to link to appt scheduling]

Opportunity 6:  Provide resources to fill in the gaps for tasks the patient or caregiver would normally have to do at home instead of resting and healing.  A list of or links to childcare, respite care, lawn service, short- term concierge services, would both give permission to rest and help locate appropriate assistance.  Tools to help patient families organize their own communities for support would also be helpful.  There is a lot left on patient family shoulders even for those who have visiting nurses and other clinical support. [Tech Op:  Foursquare, Groupon, Caring Bridge]

None of these scenarios require anything more than technology we have available today. The reality is that transformation of the discharge/transition process will take a combination of change in workflow and culture in addition to technology.

If you are patient/caregiver who has used a technological solution to help with a care transition or a vendor who has or is working on a solution addressing one of these opportunities, please comment and let us all know.

Be Sociable, Share!

Comments are closed.