Category Archives: Population Health

The important role nurses play in care transition and reducing readmissions

By Denise Barbera, RN, BSN, MA, chief nursing officer at HealthSouth  /  24 May 2017

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires that transitional care processes are under constant evaluation.

Nurses are the linchpin in the coordination of patient care, and thus are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand a great deal more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend to the patient high-value care beyond organizational boundaries.

Nurses create transitional care plans by compiling all the pertinent patient information and creating instructions to be followed. Then they share the plan in detail with all members of the new care team so that the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition of care is communication during the handoff process.

What to communicate and when

The goal of the handoff is to safely transfer the patient from one care setting to another (or to discharge the patient from the hospital completely) by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and either the new team of clinicians or the family prepares them in such a way that they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and especially in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

Many times, nurses on the receiving team care for patients for whom they lack pertinent health data. For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay extra close attention to medication communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences.

However, defective handoffs are also known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

If you enjoyed this article, you might also like: 

Nurses are vital to effective care team collaboration. Read on for resources you can use to build your own strategy.

Terry Edwards

3 takeaways from HIMSS17

By Terry Edwards  /  28 Feb 2017

More than 41,000 healthcare IT and clinical leaders converged on Orlando last week for the annual HIMSS Conference & Exhibition. This event generates a lot of industry buzz and, for some organizations, sets the stage for the year in terms of strategic focus and planning.

As I looked through the educational sessions offered in this year’s curriculum, I found it striking that nearly half of the 20 education tracks elevated the need for secure, real-time and reliable clinical communication and collaboration.

From “The Business of Healthcare and New Payment Models” track to the “Quality and Patient Safety Outcomes” track, attendees received an abundance of information pertinent to the strategic goals the industry will focus on in the year to come — goals that need a foundational infrastructure of secure clinical communications.

Here are three areas that I see most affected by the need for improved care team collaboration:

  1. Care coordination, value-based care and population health

The level of care coordination needed to successfully adapt to value-based payment models requires interdisciplinary clinicians to easily and securely communicate within — and beyond — the walls of the hospital. Regardless of affiliated organizations or geographical locations, these clinicians need instant access to the broader care team — and the patient — and they must have the ability to quickly send and receive critical PHI. This will enable hospitals and large systems not only to succeed in value-based care, but also to reduce costs and lay the necessary foundation for true clinical integration and population health.

(I talk more about this in my blog post “Healthcare is ripe for tools to enable value-based collaborative care” — read it here.)

  1. Technology, infrastructure and security

To achieve the level of care coordination required to truly address value-based payment models, organizations have to build a secure and compliant technological infrastructure that supports device standards and the communication protocols of the various workgroups that make up dynamic care teams.

Privacy, security and compliance will continue to be important objectives; the foundation of these objectives is an infrastructure that meets requirements without impeding communication and collaboration. This means automatically and seamlessly sharing information through mobile applications that are easy to use and easy to incorporate into existing workflows. Only then will we have tools that will achieve the levels of adoption necessary to make them truly impactful.

It seems like an arduous task, but it’s one we cannot shy away from.

  1. Analytics, process improvement and clinician engagement

As a result of the digitization that has occurred over the past decade, the industry has amassed a significant amount of clinical data. The farther we go down the road toward clinical integration and real value-based care, even more data will be created. To make lasting improvements and affect positive change, we have to harness this data and make it useful.

By gathering and analyzing data related to patient conditions and behaviors, intelligent decisions can be made automatically via technologies that reduce the cognitive load on clinicians by presenting only the information that is relevant to them and requires their actions. This will support value-based care and patient compliance and experience, as well as reduce costs by streamlining workflows and better engaging physicians.

In the same vein, HIMSS17 attendees were heavily focused on the topics of cognitive healthcare and actionable intelligence. Keynote speaker Ginni Rometty, CEO at IBM, spoke about this new era of medicine and challenged healthcare leaders to step up and “build this world.”

“We’re in a moment when we can actually transform pieces of healthcare. It’s within our power,” Rometty said during her HIMSS17 keynote. “This era that will play out in front of us can change the world for the better.”

The industry is changing at a speed that we haven’t seen before. This really is the time for healthcare leaders to make their voices heard and to take part in shaping the future healthcare landscape.

And it’s exciting to know that PerfectServe is in the thick of it with you — building a foundation of secure and immediate clinical communications across the broader care continuum that’s needed to achieve the goals discussed in the majority of the educational tracks at this year’s event.

Looking forward to seeing you all again next year.

March 5-9, 2018
Las Vegas, Nevada

Survey respondents

Preventing readmissions through enhanced care team collaboration

By Michelle McCleerey  /  27 Apr 2016

The Journal of the American Medical Association recently published a study which revealed that more than one in four hospital readmissions are potentially preventable. The underlying issue behind many of the key factors contributing to preventative readmissions? A lack of care team communication and collaboration—particularly between inpatient and outpatient team members. This is consistent with findings from a recent independent survey conducted by Nielsen which found that  95 percent of physician and nurse respondents believed that successful care team collaboration is key to reduced readmissions.

The JAMA study results revealed that the strongest significant predictors of preventable patient readmissions were the following:

  • Premature discharge from the initial hospitalization;
  • Failure to relay important information to outpatient care professionals;
  • Lack of discussions concerning care objectives with those patients with serious illnesses; and,
  • Emergency department decision-making to admit a patient who may not require an inpatient stay.

In accordance with the evidence, and based upon my experience as a nurse, there are a few ways care teams can avoid preventable readmissions:

  • Effective discharge planning across the entire care team—Both inpatient and outpatient care team members must actively participate in discharge planning to ensure the correct disposition and care venue for the patient. Outpatient appointments must be consistently scheduled within the needed time frame based upon the patient’s condition. Additionally, a comprehensive assessment of the patient needs and strategies to address the same must be identified.
  • Patient and family as active care team members—Patients and their family members must be full participants on the care team. It is essential for patients to contribute to and be aware of the comprehensive discharge plan to ensure that all patient/family needs will be addressed. Patients and their family members need to actively be engaged in their own care, beginning from the point of inpatient admission and extending throughout outpatient care and health management.
  • Increased collaboration between the emergency department and primary care providers—With the emergence of the hospitalist role, the common venue between primary care and the emergency room physicians has virtually been eliminated. Consequently, primary care physicians are often unaware of the patient’s visit to the emergency department and any information that is provided to them is often lacking and delayed. However, the decision to admit the patient to the hospital is dependent upon whether the patient has timely access to follow-up care. If the primary care and emergency physicians are able to efficiently connect and exchange needed information, unnecessary hospital admissions can be avoided.

As the Nielsen study found, obstacles to care team collaboration still impede such strategies, as care team members frequently do not know the correct team member to contact and waste valuable patient care time struggling to do so. Technology is needed to immediately identify and automatically connect the right care team members in order to facilitate timely collaboration. Importantly, enabling technology must provide this capability across the entire continuum and not be constrained by the four walls of the hospital.

As the healthcare industry transitions from a fee-for-service system, we must expand our focus from “discharge” to care continuity. No longer can we discharge responsibility for a patient to another care setting. Rather, we must shift our perspective and provide continuous coordinated care across multiple sites and settings. To do this efficiently, enabling care team collaboration technology is imperative.

Terry Hayes

A patient’s advocate: Nurses and technology

By Terry Hayes  /  07 Apr 2016

It’s easy for patients to feel lost in our healthcare system. Between multiple doctors, nurses in and out of exam rooms, tests, re-tests, a handful of prescriptions—not to mention the complex web of how to actually pay for care—patients can feel like they’re caught in a convoluted situation, with rules they don’t understand.

Patients shouldn’t have to feel this way. They should feel empowered to ask questions, express preferences on treatments and costs, and request their caregivers take time to explain a procedure. Of all of the care team members, nurses play the biggest role in making sure patients have a strong voice to be their own advocates in our complicated healthcare system.

I became a nurse practitioner because my passion is caring for people and advocating for them. A nurse is often the caregiver who has the most connection with the patient from end-to-end, allowing them to observe a patient’s care holistically. In some ways, the move to value-based care is really a switch in mentality to the way a nurse approaches healthcare: it’s about prevention rather than treatment of illness.

However, as the delivery of care shifts, nurses are facing an increase in responsibilities and patients, threatening to erode the core responsibility of advocating for a patient. It may seem counterintuitive, but technology can actually help nurses be more efficient so that they can still provide that critical role as patient caregiver.

For example, many nurses spend a significant amount of time in their day coordinating care, leaving less room for patient advocacy. Nurses often have to notify a full care team, which could require up to a dozen calls to identify the right clinicians. Technology makes it possible for nurses to send just one call or text to notify a full care team. For example, perhaps there’s a patient who is having a stroke. Instead of spending a half hour to find the correct care team members, a nurse can use technology to send a smart alert to all medical staff overseeing that patient – the neurologist, the pharmacist, the EEG technician – and mobilize the care team instantly.

Technology, too, can help transmit information in real time, so less time is spent in the back-and-forth of communicating. For instance, when I volunteered as a pediatric nurse practitioner for a homeless shelter, I occasionally came across a condition that I wasn’t familiar with. Video technology helped me quickly transmit images directly to a physician so that we could collaborate right then and there on what I was actually looking at so that I could continue to advocate for patients.

Adopting and implementing new technologies can be both time and cost intensive, but healthcare executives should consider the benefits and ROI the technology provides, especially as it relates to patient care. Nurses, who often know their patients best, should advocate for the technology they need and then provide leadership with first-hand testimony as to how it contributes to positive patient outcomes and recovery.

Terry Edwards

Insights from HIMSS16: Four key takeaways

By Terry Edwards  /  14 Mar 2016

Each year, thousands of health IT leaders come together over one week to network, collaborate and shine a spotlight on industry accomplishments, challenges and innovation at HIMSS. I’ve attended the show for the past ten years, and I’ve seen trends evolve over time – some fading quickly, others becoming a constant theme throughout the years – all representing the ever-advancing healthcare landscape.

This year, as I walked the HIMSS show floor and had conversations with other executives, physicians and vendors, I noticed the following:

  • The market is shifting beyond secure messaging – For three years I’ve been talking about the fact that secure messaging is an essential feature of an organizations clinical communications strategy, but it’s not sufficient in and of itself. We talked to more than one organization that experienced a failed secure messaging deployment. Having learned, those organizations and others are realizing that a secure comprehensive communication solution that can improve workflow is what is required. (It’s about time!)
  • Security continues to evolve as a top priority – Healthcare CIOs are viewing security as a major challenge, and one that must be addressed holistically. I spoke with one CIO who shared that one set of lost physician network credentials caused through a phishing scam required the reset of 20,000 user credentials – a major disruption to the entire organization. We also discussed the challenges for keeping information protected; it’s clear that more comprehensive security solutions are needed to avoid the disruptions and other setbacks caused by breaches. Healthcare security today must extend past the surface level and become integrated into workflow, communications, technology, etc.
  • Moving beyond Meaningful Use to optimization – For nearly a decade, Meaningful Use was king. Now that most providers have implemented EMRs, the conversation has shifted from fear of non-compliance to how we can do more with the EMR. More and more providers are looking for ways to optimize their EMR investment to leverage data, extend its usage and refine the technology so that it works more seamlessly within clinician workflow. Workflow plays such a critical role in care and physician coordination, and providers need platforms that are smart and holistic – ones consistent with reality.
  • Shifting viewpoints on the future of the industry – Depending on who you talk to, conversations around the state of the healthcare industry and its future, which were in no shortage over the course of the week, differ in tone. With many factors, such as regulations, driving change in the industry, it becomes easy to take on a negative mindset – physicians in particular become frustrated with balancing patient care, compliance, data and technology. One notable challenge is providers are having to figure out how to take responsibility for a whole episode of care when the patient’s full team of physicians may not all be in one system. However, innovation continues to lead the way, and this, too, was reflected in many positive conversations about the healthcare landscape today.

Healthcare will continue to build on what we have today, optimizing our existing technology to address broader issues, and do so much more comprehensively – raising new trends and challenges just in time for HIMSS 2017. See you there!

Save the date: HIMSS 2017, February 19-23 in Orlando, Florida