Supporting Transitions of Care with Technology
Wednesday, September 18, 2013
Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

Easing patient transitions and decreasing readmission rates are key priorities in the health care industry, as we strive to improve clinical outcomes and reduce costs. Case managers are often a primary conduit to a safe and effective transition process for those moving through the care continuum, which puts them in a unique position to provide invaluable education and support to patients along the way.

Thanks to advancements in health information technology (HIT), case managers and patients now have access to more tools that not only strengthen communications, but ultimately will contribute to efforts to reduce readmissions. Better patient follow-ups, enhanced education, and personalized care plans are essential in minimizing readmissions and easing patient transitions.

Promoting Transitions of Care
A new white paper, Improving Transitions of Care with Health Information Technology, from the National Transitions of Care Coalition (NTOCC) stresses the importance of improving transitions of care (TOC) through the use of health information technology. "NTOCC believes that for Health Information Technology (HIT) to make a difference in transitions of care, the technology must address several critical steps," the paper states. "The components include standardized processes, good communication, required performance measures, established accountability, and strong care coordination. Without addressing each step, the promise of HIT’s effect on overall transition of care improvement will not be realized."

The health care system has made strides in adopting health information technology to improve transitions of care, however it seems there is still some work to be done to get organizations to embrace HIT solutions to help improve transitions of care.

Information Technology Support

For the first time since the HIT Survey series (conducted by CMSA, TCS Healthcare Technologies, and several other health care organizations) launched in 2008, the 2012 Health IT Survey took a closer look at how software systems are supporting TOC and readmission prevention programs.

Specifically, the 2012 study asked respondents to describe the HIT systems they used to make transitions of care easier, how technology-enabled processes and tools are improving transitions of care, and what aspects of the software systems are supporting TOC goals.

Respondents provided an intriguing snapshot of how HIT systems are supporting transitions of care. The majority of survey respondents (51%) report using one or more electronic software resources to support transitions of care, while only a third (31%), responded that they were not using software resources to promote this initiative. The remaining 18% reported that this was not applicable to their line of work.

Communication Links

When asked about ways their organizations have used technology-enabled processes and tools to improve transitions of care through various communication links. Specific types of communication links and tools were not identified.

  • About six out of 10 respondents (58%) noted that they used communication links from inpatient to outpatient practitioners, such as between hospital and primary care physicians.
  • A slight majority (51%) noted that they communicate across providers settings, such as between hospitals and skilled nursing facilities.
  • One out of three (32%) respondents reported using technology-enabled processes and tools to improve transitions of care communication between patients and health care providers.

Readmission Prevention Activities

Survey respondents also were asked if their health care organizations utilize a readmission prevention program to support transitions of care, and a number of different TOC activities were identified in the survey. The top-four readmission prevention activities reported by respondents included post-transition follow-up phone calls (49%), inclusion of family/caregivers in the transition care plan (39%), medication review/reconciliation after transition (36%), and medication review/reconciliation prior to transition (35%).

Moving Towards a Seamless System

As technology improves and the pressure to reduce readmissions continues to escalate due to health care reform, the use of transitions of care and readmission prevention programs will steadily increase and new technologies will emerge to meet the needs of the health care industry.

A more detailed look at the "transitions of care" results will be published in Trend Report #4 in September. It will include additional tools and information to assist case managers and other stakeholders. The Trend Report will be available at and
This article was originally published in the August 2013 edition of CMSA Today, click here for the original article.