Promoting Patient Transitions
One of case management’s secret weapons is the ability to support patients over an extended period of time and through a wide range of clinical settings. Although the U.S. healthcare system is regarded as one of the best in terms of resources and innovation, it often receives poor marks in terms of care coordination. In part, this is often due to the fragmentation of the care team and system segmentation.
Among other initiatives, CMSA has been a staunch supporter of the National Transitions of Care Coalition (NTOCC). NTOCC’s website sums up its mission when it says:
NTOCC is a group of concerned organizations and individuals who have joined together to address problems associated with transitions of care: the movement of patients from one practice setting to another. During these transitions, poor communication and coordination between professionals, patients and care givers can lead to serious and even life threatening situations. These poor transitions can endanger patient’s lives, waste resources and frustrate health care consumers.[1]
NTOCC’s website is full of great resources (tips, tools, white papers, journal articles, etc.) that case managers can use to prevent or address gaps in care that impact safety and quality of care for patients, especially seniors. If you haven’t already done so, the website at www.ntocc.org is definitely worth checking out!
Stating the obvious, case managers must strive to provide smooth, seamless patient transitions. But this is not an easy task. Keeping the patient, family, caregivers, and the entire healthcare team in different settings aware of all of a patient’s care coordination needs is a major challenge. Healthcare barriers and silos need to be broken down and all healthcare providers need to work together as a collaborative team for the good of the patient. This requires commitment, communication and teamwork.
Interestingly, health information technology (HIT) fulfills an important role in supporting patient transitions of care. With so many aspects of care coordination to think about case managers need to have a care management system that helps them assess, plan, implement, track, facilitate, and document key aspects of a patient’s care. For example, care management systems provide consistency and standardization that drive “best practices” to assure expected quality outcomes and satisfying patient experiences. Assessments can capture the care needs, medication lists, gaps in care, etc. that need to be addressed. This data can then be used to automatically present suggested care plans to the case manager so that he/she can quickly send them to all members of the care team in each setting. Access to this information will allow providers to incorporate this plan into their physician treatment plan. Today this communication is done primarily on paper, or better yet by fax; but in the near future, it will be sent to a providers’ smartphone or iPad for immediate access.
NTOCC analyzed the value and effect of HIT in care transitions. They looked at the most common barriers to using HIT to improve transitions of care and identified the critical steps needed to make HIT more impactful: standardize processes, increase communication, track performance measures, establish accountability, and improve strong care coordination. Their position paper, “Improving Transitions of Care with Health Information Technology,” is thought-provoking and can be found on the NTOCC website. [2]
There are so many things to think about when trying to define the “perfect” process for transitioning a patient from one care setting to another. But we can’t give up. Promoting better transitions of care is like promoting higher quality improvement; both are never ending journeys towards something better.