Technology has created a new era of care transition that is empowering the post-acute sector while creating a shared sense of responsibility when it comes to the ultimate care of the patient.

But although care transition has been a focus for years, it has gained greater prominence due to recent pressures of readmission penalties and prospective payment models that require providers to assume more risk, said Tom Sullivan, MD, chief strategic officer for Rockville, Maryland-based DrFirst.

"The big risk for errors is from acute care to where the patient goes next – rehab, home or nursing home," Sullivan said. "Discharge plans are so complex now, but if they aren't followed closely, the patient will get readmitted, and now there are penalties. If you don't get the transition right and the readmission could have been avoided, it will cost the system more money."

Information technology is enabling providers at each care site to receive, evaluate, monitor, and, yes, nag patients to promote their health and safety. But minding the patient's health status remotely through various tech is key to preventing costly hospital readmissions, industry analysts say.

DrFirst is contributing to the care transitions process by taking advantage of the nearly universal move to mobile solutions. Its Backline product allows for chat via text or voice and includes a patient-centered chat function as well. Because the Office of the National Coordinator for Health IT has called for test and lab results in addition to an exchange of summaries, the DrFirst tool uses the mobile platform to enable exchanges beyond the desktop, Sullivan said.

One major challenge in maintaining the continuity of care during a patient transition is smoothing over the gaps where patients can fall through, said Nan Hou, RN, managing editor for Los Angeles-based Zynx Health.

"The most common gap between acute and post-acute care is hospital-to-home," Hou said. "The main problem is communication between the transferring provider and receiving provider – one-third of them don't receive documents from the hospital and only 12 percent to 34 percent of discharge summaries reach the care teams."

[Also: Post-acute IT 'getting interesting' as attention turns to EHRs, analytics, interoperability]

CMS and other organizations have developed performance measures for care transitions through various initiatives, such as: Project RED (Re-Engineered Discharge), Boston University; Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine; IHI STAAR Initiative (State Action on Avoidable Rehospitalizations); IMPACT (Improving Massachusetts Post-Acute Care Transfers); National Transitions of Care Coalition's "Transitions of Care Measures"; National Quality Forum: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination; and University of Pennsylvania Transitional Care Model.

The collective effort is to produce evidence-based guidelines for transition management, Hou said.

"Effective transition care management has a triple aim – quality of care, patient satisfaction and lower costs," she said. "Evidence-based guidelines can help providers leverage best practices by identifying problematic areas like communication and factors that contribute to the gaps."

Compliance is key

Al Kinel, president of Rochester, New York-based Strategic Interests, said there are eight types of transitions of care: Hospital-to-home, hospital-to-long-term care/post-acute care provider, LTPAC provider-to-home, patient-centered medical home and/or primary care provider to specialists, home-to-hospital, LTPAC provider-to-hospital and hospital-to-hospital.

But of the eight transitions of care that exist, the one that nobody wants is from the post-acute sector back to the acute care environment, otherwise known as the dreaded hospital readmission. Medicare is issuing penalties because transitioning in the wrong direction is a principal reason for higher healthcare costs. Hospitals may feel the immediate sting of a readmission penalty, but the process takes its toll across the continuum.

The easiest care transition is to ensuring that patients comply with physician orders – especially for patients with chronic conditions like diabetes, COPD and CHF. With its history in call centers and acquisitions of 30 communications technology companies, Omaha, Nebraska-based West Corp. hopes to provide a continuity that better enables transitions of care. 

Patient noncompliance has taken a tremendous financial toll on the pharmaceutical industry, costing drug manufacturers about $637 billion in revenue each year, according to Orlando, Florida-based AssistRx. The nonadherence results in roughly 125,000 preventable deaths and up to 69 percent of medication-related hospital admissions annually.

The company reports that “new data is proving time-to-therapy plays an important role in stopping abandonment and nonadherence,” but current manual methods of specialty drug prescriptions create what amounts to a 22-day wait before patients can begin treatment.

[Also: Hospital discharge: One of the most dangerous transitions for patients]

The AssistRx platform digitizes specialty drug management, resulting in no treatment delays and much lower abandonment rates for two drugs they studied, company officials said.

West Corp. uses a multitude of communications platforms to connect patients with providers, including mobile phones, landlines, automated voice calls, text messaging and e-mails. Through these means, providers can make assessments and look for red flags in the patient's condition. They can also facilitate appointments and medications.

 "Our primary focal point is to augment processes – the intake, insurance capture and appointments," said Vice President Fonda Narke. "But what comes into transition is staying in contact with the patient outside the four walls, a strategy to ensure patients take medications and follow their care plan. In transition, the entire point is to keep patients from being readmitted."

Company case studies show success. Reminders have boosted participation up to 50 percent, while a readmission study shows re-hospitalizations are down by 16 percent, Narke said.

Home monitoring

Non-clinical caregivers in the home are a constant and necessary presence for elderly and disabled patients who need help dressing, bathing and with other daily activities. Through a subscription service, Tulsa, Oklahoma-based Safe Homecare gives remote monitoring capabilities to family members who are separated by geography to ensure that their loved ones are being cared for properly, said COO Adam Krueger.

"This is a way for families who live in different cities and states to keep tabs on their parents," he said. "It is a way for them to stay connected."

Through a portal called the Family Room, relatives can access relevant information related to caregiving, such as which caregiver is there at any given moment and when they clock in and out; they can view and update medications and read a message board from clinicians, family members and caregivers. There is also an invoicing option that allows payments to be split among different family members.

The system incorporates elements of social media for photo posting, messaging and real-time interaction.

But the healthcare industry's progress toward a seamless transition of care is "slower than we would like, but there is progress," Sullivan said. 

“Appropriate transition of care really does require a change in workflow and mindsets among clinicians and stakeholders. Patients themselves are also responsible because they are not used to looking at their portals and medical records."

Because it is emblematic of the past, Sullivan and Hou dislike the term "discharge" and suggest it be retired in favor of "transition."

"I don't like the word 'discharge' because it has the connotation of getting rid of a patient," Sullivan said.

Hou agreed, saying that "discharge sends a message that after patients leave the hospital they are someone else's problem. Transition is a step in the health journey, not just for patients but for their caregivers." 

Discharge planners could be retitled "transition coaches" or "care coordinators," they said.

But Narke advocates a greater emphasis on communication.

"In healthcare we talk about laying the groundwork before discharge and there are materials that talk about communication between providers and patients as the key elements to drive success," she said. "The discharge process is a cognitive assessment. By asking patients the right questions, it can map out the care plan that is right for them."