Strategic Interests has deep understanding about transitions of care and how they relate to information exchange. We have performed in depth research and analysis into the care transitions of several systems, crosswalked the information exchange against national and regional standards and identified for the systems where gaps exist.
For example, take the transition of care when a patient moves from Hospital discharge to LTPAC (nursing home). There are pieces of information that are not routinely exchanged during this transition — like baseline SPO2 (blood oxygen concentration). As a result, the nursing home may have insufficient information to make clinical decisions and might send the patient back to the hospital sooner than would be necessary if they had this data. But at the present time, there is no standard to send SPO2 to the nursing home upon discharge.
Other ways transitions of care break down are with the failure to capture social determinants of health. Let’s say a patient is discharged from the hospital with a prescription for a much needed medication but that patient does not have the means to get to the pharmacy from his rural area and whatever available money the patient has is going toward securing a stable housing situation for his family. Without knowing this information and putting in place safeguards to ensure the patient obtains the needed medication, that patient will likely backslide and wind up back in the hospital — a needless readmission for a condition that could have been easily managed and a readmission that should have been easily prevented.
This is where the connection between healthcare and innovative technology becomes so critical. Systems can be adapted, workflows altered and innovative changes implemented to dramatically improve care transitions, provide better quality, reduce costs and keep patients from needless escalation of treatment.
If your system needs this kind of thinking, strategy, and implementation, ask us — this is exactly the kind of situation we love to help with!
Check out the article below in which Strategic Interests president, Al Kinel, is quoted in the context of transitions of care.