For years, healthcare has known that handoffs can make or break patient care. A good one can mean an elderly patient doing well post-hospitalization. A bad one can mean that same person returning multiple times to multiple facilities for multiple problems.
Now, a new certification offered by The Joint Commission focusing on integrated care could help facilities perfect their handoffs between levels of care, something that is particularly important as the Affordable Care Act requires inpatient, outpatient, and other community care providers to work together to maintain population health, says David Baker, MD, the executive vice president of the commission’s Division of Healthcare Quality Evaluation.
“Healthcare is changing and everyone is trying to develop an integrated healthcare system,” Baker says. But as they look at these supposed systems, what they are finding is that they may be individually great hospitals, medical homes, and skilled nursing facilities, but they don’t necessarily work well together. “This certification is to help them think about what it means to be truly integrated, not simply affiliated with each other.”
The pilot certifications often resulted in entities finding that what they thought was integration was something less than that, he says. “We will help them walk the walk.”
Until a few months ago, Baker was the chief of general medicine and geriatrics at Northwestern Hospital and worked to created real integration within that system. “When we started the hospitalist program in 2003, my office was 100 yards from the emergency department. But I could have real issues with communication.”
Within a few years, they created a system where there was an immediate email to his office if one of his patients showed up in any part of the Northwestern system, whether the patient was conscious or not. “I would get a page and see where that patient was admitted, and then eventually, to where I could go into the electronic record and read the admitting physician’s notes, any notes from the emergency department. I could see if any critical information that I knew of as the primary care physician was missed — something about the social history, for instance — and include that. That was revolutionary. That was true integration.”
This is the kind of powerful change that the commission wants to foster through the program. The process initially involves just ambulatory and hospitals entities, with eventual progress to post-acute care facilities. One of the two entities involved must be Joint Commission certified.
“We know that big quality problems seem to happen at the seams, and since accreditation looks at problems within the organization itself, we didn’t want to be redundant,” he says. So this certification looks at the connections: the discharge process, the admissions process, and communications such as expect notes from the primary care physician to the emergency room.
There are some clinical processes and quality measures that cut across both the general quality of a hospital, as well as these handoff situations, says Baker, and these, too, will be examined. For instance, at Northwestern, one issue that the integration of the system found was that patients with colorectal cancer surgery were not always getting appropriate chemotherapy treatments. “If you are truly integrated, you will have in- and outpatient teams working together to find out how many of those patients achieve optimal care. The same with other cancers, such as breast cancer. Then you would work to fix any problems.”
Another example comes from cardiology, where literature shows that only half of heart attack patients are still taking their appropriate medications six months after discharge. That’s not something that has been in the purview of hospitals before, Baker says. But as hospitals and practices begin taking joint responsibility for the health of patients, knowing who is and who isn’t doing what the inpatient specialists say they should be doing six months out is something that might benefit everyone, most especially the patient.
“Heart failure patients getting great care after two or three months, once that 30-day window has closed is another area where the two areas can really cooperate.”
Surveyors will assess how the hospitals and outpatient facilities will work together as patients move from one setting to another and back again, he says. “Using the tracer methodology, which has been a long-standing cornerstone of The Joint Commission’s on-site survey process, surveyors will evaluate how well an organization integrates information-sharing, transitions of care and hand-off communications, as the patient moves from the hospital through the continuum of care. Although the surveyors will not evaluate the actual care delivered at each site, the surveyors will visit various sites to assess the level of integration, using principally tracers, staff interviews and patient interviews.”
Readmissions continue to be a big issue for patients, payers, and the organizations that face increasing penalties for unplanned returns to hospital says Baker. By helping organizations learn to pass patients from one place to another with all the right information might just be one of the missing pieces to really tackling this long-standing problem. And by getting these different kinds of organizations to work together, they just might find issues to address the problem they hadn’t thought of before.
For example, Baker wonders how many organizations know that their discharge summaries get to the appropriate ambulatory providers within 48 hours. “This was an issue at Northwestern,” he says. “If you are at 95% a week, that doesn’t tell me what I need to know at day three about that sickest patient who comes in to see me. You need to have a way of saying, ‘This is on the electronic record within this amount of time.’”
Another thing that you might discover working together is something that shocked Baker at Northwestern: a supposedly integrated system. Just half of the patients discharged from one of the hospitals was seen at one of the clinics within two weeks, he says.
Given that there is ample evidence that seeing a primary care provider within two weeks of discharge is a key metric for preventing unplanned readmissions, Baker says this is another metric that a hospital needs to know if it is serious about attacking the problem.
“You need to be able to say what proportion of patients are being seen,” he says. “Even some mundane things are a struggle: How accurate is the PCP info in your system? Do you have a database of primary care docs so you can get appointments, and get paperwork to them?”
Another element that will be considered is integration between subspecialists and primary care providers, he says. If a patient goes to another specialist who orders tests or scans, how likely is it that that information is delivered to the primary physician? How long before it is put in the electronic record?
Baker says the added bonus for ensuring all this good communication is great patient satisfaction. He isn’t sure of data to back it up, but he says whenever he was able to talk to patients with knowledge about something that happened at another physician’s office without prompting, “they were always very pleasantly surprised. They would smile at the fact we actually talked to each other.”
So many things about transitions are problematic, Baker concludes, and failures in these areas can lead to readmissions, worse health outcomes, even death. “For the best patient care, working as a good system is important to good patient outcomes. For an organization, this will help decrease readmission rates. And while I’m unsure about the literature support, I really think it will help with patient experience measures, too.”
More information is available at http://www.jointcommission.org.
For more information on this topic contact David Baker, MD, Executive Vice President, Joint Commission Division of Healthcare Quality Evaluation, The Joint Commission, Oakbrook Terrace, IL. Email: [email protected].
For years, healthcare has known that handoffs can make or break patient care.
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