The healthcare industry is increasing their focus on communication and collaboration across the entire care continuum. The “transition of care” movement aims to share timely, accurate, and sufficient information across providers such as Hospitals, Ambulatory Surgery Centers, Rehabilitation Centers, Urgent Care Facilities, and more.
For the upstream (referring) provider, the responsibility to the patient no longer ends when they leave your facility. For the downstream (receiving) provider, there is an expectation to receive patient data prior to the transition in order to immediately assume responsibility for patient care.
The Joint Commission has a portal dedicated to Transitions of Care and their publication in the Joint Commission Journal on Quality and Patient safety states that “well-executed transitions can improve outcomes and patient satisfaction, decrease costs, and ensure that patients understand how, when, and where to seek help”[1].
That sounds great right? So how do you get there? The answer: technology. It’s time to start leveraging workflow technology to bridge the gaps within your transition of care.
Recommended Technology Tool
The Joint Commission advises their providers to use a “systematic, collaborative quality improvement process.” There are low code, Software-as a-Service solutions, such as patient experience rounding, that will streamline processes, gather all necessary data, improve outcomes and then systematically communicate those results to the downstream providers.
A dynamic workflow platform will take the best of your evidence-based practices and blend them with process automation to promote organized, standardized patient care from admission through discharge, and then facilitate the downstream transition of care.
If you’re thinking that integrating with your upstream and/or downstream partners seems like too much work or too expensive—stop right there. It’s really not. A patient rounding tool could take a simple excel spreadsheet from your partner provider and map to your system for immediate, digital access.
Alternatively, if you’re looking for a more sophisticated solution, a flexible workflow solution could create a bi-directional connection via web services or HL7 compliant interface. Options are available to fit any need and budget.
Recommendations for Success
A well-designed transition of care strategy will have:
Established “Best Practice” processes
You can’t improve without a process. Establishing standardized processes allows providers to focus proactively on how to improve versus spending valuable time and money putting out fires. Whether you are a rehabilitation center, an ambulatory surgery center or nursing care center, there are industry standards published for best care practices which can be used as a reference so you don’t have to start from scratch.
The right workflow technology partner will work with you on this effort. That partner will then take those processes and help you streamline them by adding automation in order to create consistency, increase visibility and reduce costs.
A Transitions Team
When establishing best practices for care transitions, The Joint Commission established a “Safe Transitions Team” to develop and disseminate those practices. We recommend taking a similar approach and establishing a team dedicated to establishing protocols for care transitions and ensuring the appropriate technology is leveraged. This team does not have to be full-time of course and should consist of stakeholders from different practice areas within your organization.
Strategic Partnerships with Upstream and Downstream Providers
Focus on establishing relationships with your preferred referring and receiving partners. Your choice partners should be equally as innovative and dedicated to continuous improvement across the continuum of care for their patients.
You can take the lead in identifying the technology you want to invest in, but feel free to invite your referring/receiving partners to the table for joint demonstrations and discovery sessions. This will help with adoption later and could even result in partnering to share technology costs. Don’t forget—set mutually agreed upon performance metrics with your partners and manage them together.
Recommended First Steps
Identify your biggest challenge
Identify the point surrounding the transition of care where are you have been experiencing the most challenges and/or have the biggest gap. This is your starting point. Trying to tackle too many processes at once could result in analysis paralysis and stall your efforts.
Identify your potential technology partners
An investment in technology doesn’t have to be a daunting task. You can perform research yourself before selecting companies to reach out to. Send your challenge (identified in Step 1) to each potential solution and let them demo their product to you. Look for industry knowledge (an understanding of your upstream and downstream providers), interoperability (ability to communicate with other systems) as well as scalability.
Implement the chosen solution for one process
Have your Transition Team implement the solution around the identified challenge, track the results and then scale across the organization to other processes incrementally.
The key is to start small, identify valuable partners and focus on challenging and reinventing your processes. A focus on continuous improvement of your transition processes through the use of smart technology will translate to improved outcomes and a better patient experience.
[1] Hannah Shamji, MPH; Rosa R. Baier, MPH; Stefan Gravenstein, MD, MPH; Rebekah L. Gardner, MD. The Joint Commission Journal on Quality and Patient Safety. Improving the Quality of Care and Communication During Patient Transitions: Best Practices for Urgent Care Centers. July 2014, Vol. 40, Number 7.
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Jane Mason, Founder and CEO
Jane has applied her vast experience (over 25 years) operating process-driven businesses to successfully redefine client-focused service. Jane has worked with expert programmers to apply cutting-edge web-based technology to automate complex processes in industries such as Financial Services, Healthcare and enterprise workflow. Her vision confirms Clarifire's trajectory as a successful, scaling, Software-as-a-Service (SaaS) provider. A University of South Florida graduate, Jane has received many awards related to her entrepreneurial skills.
