Embedding Evidence-Based Medicine into Transitions of Care


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

Population health is a journey over time and provider organizations understand they must begin with the most impactful programs. Providers have to prioritize and focus initial efforts to quickly bend the needle on patient outcomes such as reducing readmissions. When organizations ask me where others are seeing tangible initial success, I often tell the following story.

An outpatient care manager at one of Caradigm’s existing customers shared with me that the value of population health technology became clear for her after getting a real-time alert one day that one of her patients was in the ED. She called the ED and was told that the patient’s blood glucose levels were extremely high, and the ED nurse thought the patient should be admitted. However, the care manager informed the nurse that the patient’s numbers were actually the patient’s baseline, and recommended that the patient did not have to be admitted, which saved an unnecessary admission. The outpatient care manager was able to devise and implement an effective plan of care to address a variety of contributing barriers to care, and the patient outcome was improved.

This story is about taking the right action, in the right time frame, in the right care setting. In other words, how do you embed best practices into workflows to reduce variation in care? How do you help patients move through a confusing and disjointed healthcare system that can be overwhelming to navigate? Transitions of care is an area central to population health that for many organizations is an excellent place to focus your population health efforts. The following are a few best practices to think about as you develop your strategy.

Facilitate access to primary care

Coordinated care is a proven value for high-risk patients, however, it is often a challenge for patients to access primary care soon after being discharged. Some organizations have found it effective to enroll high-risk patients into a Patient Centered Medical Home (PCMH) as a standard practice to get them better connected to primary care, a care coordinator and other community resources. Another approach is to partner closely with primary care clinics and even embed a care manager, a transition focused mid-level practitioner or social worker into the clinic to specifically serve high risk transitions patients. Even offering telephonic transitions of care support to coordinate scheduling for patient can help.

Standardize interdisciplinary care

When multiple levels of clinicians partner effectively with defined pathways and shared information, it’s amazing to see the impact. For example, psychiatrists and social workers going to a PCP’s office to speak to patients. Pharmacists calling physicians to say a prescription ordered is far more expensive than other options. Home health that directs patients back to lower acuity centers if needed, and works with patients to prevent unnecessary ED stays. Some provider organizations have had success identifying non-employed physicians interested in adding home visits as an additional revenue opportunity. Population health is truly a team sport and technology can help support transparency and care traffic control, making patients more confident in a team based delivery model.

Embed practices into workflows

After establishing your care protocols and pathways, care management tools can help ensure they’re followed consistently. Intelligent plans of care can have pathways embedded in the patient care plan, assuring that steps aren’t missed. Role-based tasking can help a team of clinicians take the right steps, in the right sequence, all while working at top-of-license. As mentioned in the story earlier, alerts can let the appropriate care team member know when a patient has a change in status, whether an ED visit, observation stay or inpatient admission. Lastly, as it is common for patients to be managed in multiple EMRs, technology can play a big role in streamlining medication review and in overall information sharing by aggregating data from multiple EMRs. Performing standardized readmissions assessments can help determine root cause, support an automated plan of care to mitigate barriers and perhaps even identify patterns or discharge practices of care that require change.

Improving transitions of care, supports long term success in advancing quality, patient experience of care as well as managing the cost of care. Organizations should be thinking about strategies for scaling, risk stratification, solving for social determinants and reducing variations in care. Wherever your organization is today, if you focus on meeting patients where they’re at and guiding them through what is a complex healthcare system, you will have succeeded in a foundational strategy for long term success.