Hospitals and health systems acknowledge that they need to do more to improve care coordination with post-acute care providers, according to a new NEJM Catalyst survey, Sandra Gittlen reports.
The survey of 375 clinical leaders found that:
- 7 percent of respondents said their patients' care was fully coordinated between the inpatient, post-acute, and home settings;
- 30 percent said care was mostly coordinated;
- 53 percent said care was somewhat coordinated; and
- 10 percent care was not coordinated.
Several respondents offered tips to help organizations better manage care coordination.
Edward Kersh, medical director for telehealth at Sutter Care at Home, told NEJM Catalyst that quality leaders have been overly focused on the hospital setting when trying to reduce readmissions. "Post-acute care will improve when more attention is paid to its role in patient outcomes," he said.
Nathan Gilmore, assistant in quality improvement at Hoag Memorial Presbyterian, said his organization has made strides by using a preferred post-acute care network in which post-acute and inpatient providers have access to "real-time, easily accessible information."
Hoag's preferred acute-care providers have access to the same EHR, lab, and radiology systems as Hoag. But technology goes only so far. Gilmore said the best strategy to improve care coordination is to send Hoag doctors out to round at skilled nursing facilities. "By deploying our own resources through contractual and informal relationships, we've seen decreased bounce-backs to the hospital as well as improvements in acuity measures," he explained.
Valley Children's Healthcare in Madera, California, faced a shortage of high-quality post-acute care providers in its service area—so it launched its own home health service called Valley Children's Home Care, explained Patrick Burke, a pediatric hospitalist at the hospital.
Burke added that the growth of value-based payments can be a powerful force to increase coordination between the inpatient and post-acute care settings.
According to the NEJM Catalyst survey, improving real-time communication between hospital, post-acute, and primary care/outpatient providers is the top opportunity to improve transitions between care settings.
Sutter Care at Home's Kersh, meanwhile, strives to overcome communication barriers by meeting with local hospitals' readmissions committees. "[Kersh] also speaks to cardiologists, hospitalists, discharge planners, primary care physicians, administrators, and other key players about what happens in home health care for heart failure patients," Gittlen writes.
Kersh also engages staff on the post-acute care side to make sure they understand the best ways to communicate with other types of providers. For instance, home health staff can avoid ED admissions and hospitalizations if they understand the role of hospice agencies, he said.
On the inpatient coordination side, Kersh trains staff to communicate in a way that engages doctors. "You don't call up the cardiologist and say, 'Your patient has gained five pounds, what should we do?'" he explained. "You say, 'Your patient gained five pounds, should we double the Lasix dose?'"(Gittlen, NEJM Catalyst, 11/22; Compton-Phillips/Mohta, NEJM Catalyst, 11/10).
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