Bridging the Transition to Home: Tips for Care Coordinators

According to a 2012 study, one in 12 Canadian patients is readmitted to the hospital within 30 days. Why do so many people who have been discharged wind up back in acute care? In many cases, the answer may be faulty discharge planning and poor communication.

Providing adequate care for a single at-home patient can be a complicated process—one that may involve dozens of care professionals. As a care coordinator, you’re there to ensure that care information is up-to-date and in the right hands. But this already-difficult job can become even more challenging during care transitions.

Like so many issues in health care, difficulties related to care transitions are often related to poor flows of information. When many professionals from primary, acute, and community care are involved in one process, communication breakdowns are bound to occur.

It’s patients who suffer the consequences. Knowing this, care coordinators like you put a lot of pressure on themselves.

In our last post for care coordinators, we looked at ways to reduce a patient’s frustration during a move back into the community. In this post, we’ll consider the overall importance of communication during this transition.

The Patient Perspective

The Harvard Business Review found that the biggest factor in reducing readmissions is communication between patients and caregivers. By improving communication with patients, hospitals could reduce their readmissions by an average of five per cent.

Not only that, but home care recipients frequently express a strong desire to know what will happen in the weeks following their discharge.

Are they completely clear on how to perform relevant self care tasks? Who can they call when they need help? Is there a roadmap for the weeks following their discharge, so they know where they’re going? Do they know they’re not alone?

Of course, ensuring that these needs are met is a big part of the job for care coordinators. By listening and offering individualized support, you provide immeasurable comfort. But there are times when the complexity of the system gets in the way.

For example: you can collect the information you need from relevant hospital, community, and primary care providers. But can you facilitate productive, ongoing communication between past and current care team members?

You can create a detailed care plan based on patient needs and preferences. But can you be sure that all members of a patient’s circle of care will provide regular updates?

When the answer to questions like these are “no”, how does it change the patient experience?

Care coordinators are there to help patients understand what’s happening. You provide structure for their care as well as personal support. While your role is absolutely critical, it can also be undermined in the eyes of patients when things don’t run smoothly. Knowing things aren’t going exactly as planned can lead to feelings of fear and loneliness—even when you’re there to help.

Provider Perspectives

It’s the patient who matters most. And she should always be at the centre of her care. But the perspectives of the many people involved in caring for her are far from irrelevant.

By identifying the biggest challenges providers face, you can ensure that the right information gets to the right person at the right time.

For one thing, care coordinators should remember that workflows can be particularly complex during care transitions. Consider it from the practitioner’s point of view. A specialist assessing a new at-home patient may have to deal with many unfamiliar providers. Does he know who to contact to get that set of test results he needs?

When care team members are out of sync, actions are often duplicated. Precious time and resources are wasted, and the health care system doesn’t operate optimally. Improving communication and the flow of patient information would do so much to make care transitions better.

Care coordinators do a lot to improve these processes. But you can’t always be there to remind providers of the importance of sharing information with other care teams members. Despite best intentions, there are bound to be delays and omissions.

In some cases, practitioners underestimate the impact of careful coordination. Often, those who have been part of the system for years (or even decades) are hesitant to change how they do things.

Still, few would refute the fact that it should be easier for providers in acute, primary, and community care to work together toward patient progress. When it connects to their daily frustrations, care providers can clearly see the need for change.

To understand the difficulties faced by practitioners during care transitions, it can help to consult relevant resources meant for nurses and other providers. This set of care transition recommendations from the Registered Nurses Association of Ontario (RNAO) is a good example.

Connecting the Circle of Care

Care coordinators know the value of their work. And now, more and more health care professionals are learning about very real benefits to coordinating care for high-risk patients. Consider the work of Illinois-based Advocate Physician Partners (APA).

The organization, which is devoted to population health management, found that better coordinated care resulted in costs that held flat or decreased by 2 to 3 per cent over three years.

How can other health care organizations achieve similar results? Ontario is moving forward through the implementation of Health Links. Focusing on creating centralized care plans for high-risk patients is one of many positive steps.

That said, there’s room for improvement. Today, care coordinators are navigating a shifting health care landscape. The complexity of managing transitions can compound existing challenges.

Advocating for thorough, early discharge planning can go a long way toward improvement. You have a lot of knowledge for the acute care practitioners in your professional circles. Help them understand the value of ensuring that everyone within a patient’s circle of care has the information they need ahead of time.

For example, busy professionals can forget how difficult it can be for patients to forget self-care instructions when they get home. When printed instructions are issued, it can help patients—and you, since care coordinators are often the ones who field questions from care recipients.

In general, preparing for inevitable weaknesses in communication chains is important. Nurses, doctors, specialists, mental health providers, pharmacists—these care team members may be spread out across different care provider organizations.

While you’re there to do a lot of the crucial organizational work, the many professionals involved need to access relevant, up-to-date information in one place.

Luckily, digital technology offers effective solutions. The right system can provide the infrastructure for secure, real-time information sharing. It can support online care plans and ensure that all of a patient’s health info and care instructions are available to those who need it—when they need it.

Care Coordinators

There’s no doubt about it: without ongoing communication between providers, care transitions won’t be smooth. And when things don’t run smoothly, there can be real consequences for patients.

Care coordinators have perspective on the common communication problems that occur between health care organizations and care professionals. For this reason, you’re in a good position to help assess and select a communications solution.

Feature image courtesy of Presidencia de la República Mexicana

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