Before the Patient Protection and Affordable Care Act, the healthcare industry was, "more or less, smooth sailing," said Matt Tanzer, chair of the National Transitions of Care Coalition's Healthcare IT Innovations Task Force, in a recent webinar.
"Revenue was increasing, employment was growing," he continued. "There was little financial justification for serious investments in transitional care quality. Readmission was a poor patient outcome, but not a poor financial outcome."
Now, the transition from fee-for-service to fee-for-value is causing healthcare providers to refocus on preventing readmission. While it has certainly been a period of adjustment and transition, Mr. Tanzer said improving the transition of care process can help providers decrease readmissions and improve their competitive advantages.
"Transition of care is a matter of life and death for patients," Mr. Tanzer said. "It's also a matter of life and death for provider systems."
As such, software IT companies are developing provider solutions to enhance, assist and optimize care transitions to ensure patients stay home after being discharged from the hospital.
During the webinar, five executives of health IT companies that developed software to address care transitions shared their products and suggestions on how to improve quality transitions while reducing readmissions. While their products addressed different elements of a care transition, they all also had one resounding theme: It takes a community to ensure proper, adequate care.
John Zicker, COO of Vree Health, which develops patient engagement and care coordination platforms, said coordinating all the members of the patient's community of caregivers is a main challenge in care transitions. "The key crux of this is how do we get the engagement both from the patient side of things and on the other side the entire care community that interacts?" he asked. "On the same page is a great problem of how [to] disseminate a care plan. How do you get that out in front of all the parties concerned, because we all share the patient in healthcare."
The CEO of RightCare, Eric Heil, said that in addition to communicating care plans with everyone involved, providers need to assess the level of post-acute care patients need as well as understanding the root cause of reasons for readmissions. "The root causes of why patients are readmitted is not medical diagnosis or procedures. It's psychosocial, socioeconomic elements that are critically at play to understand where the patients are coming from." RightCare sorts and prioritizes cases so case managers can efficiently use their time and resources.
In terms of a patient's community of caregivers, designating appropriate duties to different people can also help improve the quality of care transitions, suggests Andray Ostrovsky, MD, CEO and co-founder of Care at Hand, a solution that helps separate the clinical roles and the direct care worker roles of a nurse. Dr. Ostrovsky said reallocating responsibilities ensures each member of the care team is providing their expertise in their niche area. While a nurse still carries out clinical duties, a direct care worker might oversee social issues.
Similarly, Ken Accardi, founder and CEO of Ankota, a care coordination platform, said assigning care transition coaches can be a key tool in a quality care transition plan to ensure patients are not readmitted to the hospital. "The best place for someone to be is not in the hospital," he said.
While patients rely on their community caregivers in post-acute care services, engagement and self-empowerment are also important for treatment, said Drew Kraisinger, vice president of innovation and strategy at Medecision, which provides a communication and data sharing platform for patients and care providers. Part of self-management is helping connect patients with their caregivers and reaching out to them when needed. "The patient or consumer is in the driver seat," Mr. Kraisinger said.
Care transitions are coming into focus as lucrative areas in the march toward fee-for-service, and the health IT sphere is stepping up to offer providers services to stay afloat.
"It's a tremendous opportunity for transitions of care professionals to make a business case to executive leadership to invest in technology to lead to sustained lasting results to create competitive advantages for organizations," Mr. Tanzer said.
More articles on care transitions:
Study: Guidelines, feedback interventions can improve communication during patient care transitions
Study: Care Transitions Intervention, Including Home Calls, Results in Cost Reduction
4 Ohio Hospital Join Care Transitions Program to Reduce Readmissions in Medicare Population