Improving Provider Communication and Patient Transitions

Hospital-Based Best Practices

Topics: Quality, Performance Improvement, Continuum Integration, Methodologies, Patient-Focused Care, Communication Skills, Skill Development, Workforce

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By reading this study, members will learn how to better:

  • Ensure inpatient care team members are in agreement on the patient’s plan of care
  • Deliver truly interdisciplinary care
  • Restructure case management and care planning to decrease LOS and improve transition planning
  • Set up the infrastructure to safely hand off patients to the next site of care
  • Ensure high-risk patients are managed in the inpatient and post-discharge settings to reduce risk of readmission
  • Instill accountability among patients and physicians for improving transitions of care

Executive Summary

Significant funding at stake for care transitions

The burning platform for care coordination is the financial implications—both on the upside and downside—outlined in the Patient Protection and Affordable Care Act (PPACA). First, the Readmissions Reduction Act proposes to penalize hospitals for excessive 30-day readmissions for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. In FY 2013, hospitals stand to lose up to 1 percent of total Medicare operating payments. Secondly, the Act offers financial support to assist hospitals in the highest tier of readmission rates for those three conditions through the Quality Improvement Program and the Community-Based Care Transitions Program, which allocates $500 million in funding to improve care coordination for high-risk Medicare beneficiaries. The signal value of this funding cannot, and should not, be overlooked by hospitals.

Hospitals currently plagued by poor care coordination

The increased scrutiny on care transitions is largely driven by the unnecessary costs and poor outcomes attributed to substandard coordination. In the inpatient setting, lack of communication among members of the care team prolongs length of stay (LOS) and compromises the quality of care provided. Similarly, fragile handoffs to outpatient providers create needless duplication of services and pose risks to patient safety.

Beginning to migrate from siloed to seamless care

However, under accountable payment models, hospitals will be charged with improving quality outcomes and reducing unnecessary utilization. Improved care coordination both in the inpatient and outpatient setting will be critical to success from all angles. Yet, the relationships and operational processes needed to deliver more seamless, high-quality care, will not be developed overnight, and those hospitals that embark on the journey today will obtain a competitive edge. As such, this publication provides 16 best practices for improving inpatient care team communication, enhancing care transitions, and instilling accountability among key stakeholders.