By Melinda Young
The care transition process is challenging, especially for patients with multiple complex conditions. To provide the best care to high-risk patients, case managers, community providers, and clinicians need to optimize communication.
Case managers can improve the process through quality improvement efforts that focus on overcoming dialogue challenges and identifying providers’ communication preferences.1
Information about patients’ care can be lost during the transition process, says Ann Scheck McAlearney, ScD, MS, an associate dean for health services research and the executive director of CATALYST, the Center for the Advancement of Team Science, Analytics, and Systems Thinking, at The Ohio State University College of Medicine.
If the goal is a seamless care process for the patient, the focus should be on seamless communication. “In a situation where a patient is transitioning from specialist to primary care provider to hospital to home or to another hospital, all of the information that was learned in the prior situation needs to be transferred with that patient in order to make that transition seamless,” McAlearney explains.
This is how case managers and providers can preserve the care in a patient-centered way. “When patients are transferred, they’re repeatedly telling people what their medications are and what their surgeries are, and it’s not helpful to patients to keep repeating,” McAlearney says. “It’s more accurate to have a medical record that’s up to date and that follows the patient [to each setting].”
That is the ideal. But except for patients who stay within in one large health system (e.g., Veterans Affairs), that is not the reality. “The big issue is patients don’t necessarily stay within the system,” McAlearney says.
Sick patients who travel to a large city’s health system for care often return to their small town’s providers, who do not have the same — or any — electronic health record (EHR). It can take many extra steps for hospital case managers to send the updated medical information to the community providers.
“The patient leaves the hospital and goes home, and everything that happened in the hospital may not be tracked somewhere else,” McAlearney explains.
Navigators Can Help
One way to ensure better communication during transitions is for health systems to employ navigators to contact patients’ community providers. “A navigator is a fantastic solution if that’s available,” McAlearney says. “They understand what happens and can communicate to the next place.”
Since the role can be costly, some health systems provide a navigator for certain departments, but not for all patients with complex medical needs. “Patient navigators may be well used in the oncology space, but not somewhere else,” McAlearney explains. “It’s an expensive resource.”
Healthcare organizations with enough financial resources can create navigation and protocols for transitions and communication between inpatient and ambulatory settings. But not every health system has the resources for this, so other solutions also are needed.
Without a navigator, there is the problem of relying on the provider the patient saw at the medical center to call the referring clinician in the patient’s community. “The best way to do that is to have very strict protocols for what happens, who makes the call, and who makes a follow-up call,” McAlearney says. “Some health systems have protocols and checks and balances to make sure it gets done.”
Many healthcare organizations use EHRs that can communicate with other organizations. But even when the technology is optimal, it is not as seamless as a single healthcare system’s communication with its own staff and providers.
“The contrast is the VA system or Kaiser Permanente, where it’s all one system and data flow seamlessly within a single system, and patients don’t go outside that system to receive care,” McAlearney says. “Making it easier to make those coordination efforts 100% of the time is part of the goal.”
Since most health systems now use portals that list medical care and procedures, patients could show their hometown physicians the information on these portals. But that is an imperfect solution.
“There are patient portals, but there are issues around health equity that are of concern,” McAlearney says. “Most of that type of communication relies on patients being English-speaking.”
Patients with limited English proficiency may not be able to access interpreters in all healthcare settings. Also, patient portal access is not uniform across different geographical areas.
“Some places don’t have broadband access, so it doesn’t work,” McAlearney adds. “There’s a digital divide, and people don’t have the same level of access to electronic data.”
If patients cannot access their own chart online, then they cannot communicate the information to the provider, McAlearney says. Carrying and sharing their medical data on a digital memory stick could lead to privacy issues. Many patients do not have access to printers.
One of the best solutions would be to train hospital case managers to communicate with ambulatory providers and connect patients to post-discharge resources and ensure their records are transferred. They can fax the records if that is the best option, but case managers also would need to contact the patient’s referring or community providers to ensure they received the records.
“It depends on the size of the system and the size of the workload, but this could be part of the case manager’s job,” McAlearney says. “Write a new job description.”
REFERENCE
- Beal EW, Kurien N, DePuccio MJ, et al. Provider-to-provider communication about care transitions: Considering different health technology tools. J Healthc Qual 2023;45:133-139.
The care transition process is challenging, especially for patients with multiple complex conditions. To provide the best care to high-risk patients, case managers, community providers, and clinicians need to optimize communication. Case managers can improve the process through quality improvement efforts that focus on overcoming dialogue challenges and identifying providers’ communication preferences.
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