In 2013, approximately 7.96 million patients discharged from an acute care facility required some type of post-acute care service, representing 22.3% of all acute care discharges. With changes in reimbursement and providers assuming more risk, it is understandable that health systems and providers are seeking to better understand and manage this patient population.
Traditionally, post-acute care has been fragmented and disjointed at every level with little investment in creating a seamless transition across the care continuum. I entered the post-acute world in late 2009 and was astonished at the accepted paths of communication between health systems, providers, and the post-acute care companies caring for these patients. In my experience, I would say that the most accurate way to describe the coordination of patient care in this environment is ‘poor.’
In the overwhelming majority, there is no efficient collaboration between the acute care and post-acute care worlds. Providers have been left to piecemeal and bootstrap their own, oftentimes clunky and cumbersome, solutions for the ongoing communication required in managing this patient population. These solutions tend not to be secure and are woefully inadequate, lending to the issue of readmissions and sentinel events that have plagued our health care system.
The amount of information that needs to flow between providers and the companies caring for these patients can be daunting, especially when the provider has another patient population to manage that is in the acute setting. Traditional landlines and fax machines are sadly the standard in coordinating patient care and the reliability is just not there. Today’s providers are busy and often will not immediately receive that fax or voicemail seeking orders to deal with a critical lab value, evaluate a concern for a post OP infection, or make decisions regarding end of life care. The RNs in the field visiting these patients have done the best they can with the means they’ve been given but the ability to securely communicate in an organized and timely fashion has remained out of reach.
As mentioned above, the days of patients getting readmitted to the emergency room due to inefficient communication are drawing to a close, thanks to penalties in reimbursements that providers are facing. There are options that exists today with pMD® Clinical Communication™ that allow for a seamless and timely flow of communication between post-acute providers in the field and the physicians that are following their care.
This can currently be done in real time - issues brought up and issues solved by creating a secure, direct line of communication between individuals responsible for the care of these patients. The ability for a physician to quickly shift from one population to another, review pertinent historical information, and issue orders of corrective action directly from their smartphone exists. If properly implemented, it can make a difference in the outcome of the patients we serve and avoid the readmission penalties that have hurt providers.
With just a small amount of effort, the abilities and impacts are nearly endless in bolstering the communication between the acute and post-acute worlds. For example, the ability for a physician and collaborating pharmacist to receive an automated alert to their smartphone or desktop which is tied to a specific patient, would solve a persistent and frustrating problem in that community that often requires printed or faxed documentation. Oh, and it also creates a better situation for the patient, reducing the potential negative impact on their well-being.
This is just one example, but it is a scenario that I have seen play out numerous times over. Enhancing our communities’ ability to talk and share documents, photos, and video efficiently in a HIPAA-compliant fashion can improve outcomes and save lives. That is what we are here for ... isn't it?