Elevating Communication During Care Transitions

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The effects of consistent, reliable care transitions on clinical care and financial outcomes

Care transitions—especially those that involve moving a patient from the acute to the post-acute setting—are often fraught with poor communication and a lack of cross-continuum information-sharing, resulting in care lapses that can lead to medical errors, unnecessary hospital readmissions and other negative clinical and financial consequences. However, forward-thinking organizations are realizing the importance of improving these transitional periods in order to reduce risk, boost care quality and sustain positive patient outcomes and satisfaction, even after a patient leaves the hospital.

Community Regional Medical Center (CRMC)—a locally owned, not-for-profit, public-benefit health system based in Fresno, Calif.—is one of these forward-thinking organizations that has committed to enhancing its care transitions. With four hospitals as well as several long-term and outpatient facilities, the organization is the region’s largest healthcare provider. It is home to the only Level 1 Trauma Center and comprehensive burn center between Los Angeles and Sacramento, and it is licensed for 900 beds, regularly seeing 95 to 100 percent occupancy. The center is constantly moving patients to other care settings, and because of its size and prominent role in the community, it recognizes how making care transitions more consistent and reliable could have far-reaching effects in terms of both clinical care and financial outcomes.

Encouraging Standardization

One of the reasons why care transitions have been so risky is that communication during these times has historically been uneven and unpredictable. To address this issue, CRMC aimed to standardize its processes for discharge communication as much as possible. One particular area that warranted attention was related to the information the organization initially communicated with potential post-acute providers. It used to be that almost every provider the center worked with had slightly different requirements for what they wanted to know about a prospective patient, and its discharge planners spent a lot of time customizing patient information packets to meet post-acute organization requests. In addition, some facilities preferred to receive information via fax while others wanted an email or even a phone call. These process variations made communication cumbersome and time consuming for discharge planners—not to mention it could take many cycles until suitable organizations were found that met a patient’s specific needs.

In January, CRMC revamped some of its discharge workflow by implementing a technology solution that standardized both the content and format of communication, streamlining the entire post-acute provider identification process. Now, discharge planners can quickly generate a detailed sheet of patient information and, with a few keystrokes, send it to all the facilities that have the potential to meet a patient’s clinical and psychosocial requirements. The center sets response time expectations with the post-acute providers, requiring them to give an answer within 24 hours as to whether they are able and willing to accept the patient. Once CRMC hears back from the various organizations, a list of appropriate facilities is generated for the patient and family’s consideration.

Promising Results

As a result of the technology, CRMC has cut significant time off post-acute provider identification and also improved the quality of the possible provider list. This is apparent in a recent example, when the organization was preparing to discharge a highly complex patient who required very specific post-acute care interventions. The discharge planner was able to easily generate a comprehensive patient information packet and electronically distribute it to 1,000 potential facilities across California simultaneously. Within a day, CRMC received 24 responses and was able to offer the patient and family a relatively short list of optimal facilities to consider. Prior to implementing the system, it would have taken days and a lot of manpower to generate this same list, adding substantial costs to the patient’s care and negatively affecting their satisfaction.

CRMC also tracks the impact of the new technology by keeping an eye on the number of avoidable patient days — where the patient is ready for discharge but there is some preventable barrier, such as a delayed consult, lack of identified post-acute facility or other roadblock, which holds up the transition. Though the technology was just recently implemented, CRMC has already noticed a decrease in the number of avoidable patient days.

In addition to increasing efficiency, the technology is also impacting quality of care for patients, especially those with complex care plans. Since discharge staff is no longer spending considerable time generating information and waiting for responses from post-acute providers, they can focus attention on those patients who need a more hands-on, customized discharge approach.

A More Consistent Transition

By working to normalize its discharge communication processes, CRMC has taken a large step toward reducing care gaps and improving the predictability of these high-risk times. While there is still more work ahead, the organization is committed to evolving the discharge process into a highly reliable function that streamlines the movement between settings and preserves patient health.

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About Author

Mark Kestner
Mark Kestner

Mark Kestner serves as the chief medical and innovation officer of Community Regional Medical Center in Fresno, Calif., an academic-affiliated medical center with UCSF. In this role, he is responsible for all clinical operations and the development of new models of care to improve operational efficiency, improve resource utilization while improving the overall health of the population in California’s Central Valley. He has implemented Health Care Efficiency and Logistics Platform (“Air Traffic Control Center for Health Systems”) and TEAM CARE model of patient care. Kestner received his medical degree from the University of Michigan, completed a general surgery residency and began his surgical career in the U.S. Army during which he completed a critical-care and trauma surgery fellowship at Jackson Memorial Hospital at the University of Miami. He completed his MA in Executive Leadership through Gallup University and his MBA through University of Nebraska. Kestner has spoken in many national and international forums on these topics related to innovation in healthcare to include Center for Healthcare Transformation, National Press Club, and before the House Committee on Energy and Commerce Subcommittee on Health.

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