Care Transitions + Clinical Communication – Key to the Readmissions Equation

By Leigh Ann Myers  /  21 Oct 2013

I spend a lot of time discussing the need to fix broken clinical communication processes in hospitals. That’s partially because I’ve experienced these issues personally, but also because I’ve spent much of my career trying to address them. The clinical communications problem that challenges the industry now extends beyond the four walls of the hospital, and this has serious implications when it comes to reducing readmissions to avoid costly CMS penalties.

Today, when patients leave the hospital, their care is transitioned to a range of different folks – from care coordinators to home heath managers to primary care physicians to nursing homes. Each of those entities likely prefers to be contacted in a range of different ways, at different times and with different types of information. If that system or process is flawed or cumbersome, the result is that the necessary information doesn’t reach the right outpatient coordinator – whoever it is – and the patient is at risk of missing follow-ups, skipping a medication or experiencing delays in the care they’re provided.

For example, say an outpatient care coordinator is following a chronically ill patient.

  • Step 1: The patient arrives in the ED and is admitted to the hospital. Is that outpatient care coordinator notified? Is the PCP? And how? Is there a way to confirm that message was received?
  • Step 2: The patient is admitted to the hospital. Is the outpatient care coordinator notified at this point? The PCP? How do they know or find out what happened to their patient while they were in the hospital?
  • Step 3: The patient is discharged, and told to follow up with primary care in 48 hours. Does the care coordinator or PCP know this? If the patient forgets to schedule an appointment, who is responsible for follow up with them? If they do schedule an appointment, does the PCP or care coordinator know what medication they were sent home on, or what the results of lab work were?  Is it easy for them to obtain this information, or will it cause a delay in patient care?

These questions get to the root of the problem – it isn’t about technology, it is about process. Effective communication processes are complex to determine and implement, but they are key to balancing the readmissions equation. I know I want my family members’ care team (inpatient and outpatient) talking to each other, helping them remain healthy and out of the hospital.

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