Paving the Way for Patients' Transition of Care

Transition of patients from acute care setting to a skilled nursing facility has been increased complexity due to reimbursement models and also due to the high acuity for when the patient makes that transition. It is also important to have an accurate presentation or picture of the patient when they make this transition. This presentation will introduce barriers in transition of care, the different type of technology tools to support patient centered care, and strategies to support meaningful-use. The transition of care from one health care setting to another can be complex; but when a patient goes from an acute care setting in which there is an increase in the comorbidities of the patient, transitioning to the skilled nursing facility can be quite difficult. The breakdown in communication of the presentation of the patient has been linked to poor patient outcomes, dissatisfaction of care, and increased hospitalization (Bates, et al., 2003; Naylor & Keating, 2008). There are many factors that contribute to this breakdown including poor communication, incomplete information, and absence of a single point person.

In 2009, the United States government set a precedent that recognized the importance of health information technology (HIT) for patient care outcomes. The American Recovery and Reinvestment Act (ARRA) was formed and introduced meaningful use (MU) (McGonigle & Mastrian, 2015). MU are the rules and regulations that were set forth to reimburse provider practices and hospitals who have demonstrated that the information was provided in a meaningful way through their electronic health record (EHR)(Sherman, 2013). MU has three stages that started in 2011 and goes into 2016. This presentation will focus on stage two which included the transition of care using electronic means to share data.

Our institution developed an electronic delivery of a transition of care report that would flow from the acute care setting into the skilled nursing facility EHR. This report included the medication that the patient was taking, allergies, the diagnosis of the patient, the hospital course of treatment, past medical history and recent lab values. This report was updated right before the patient moved from on form one facility to the next. On the document, the primary provider’s name is included along with how to contact them. The transition of care report pulls data out of the EHR and is sent electronically when the provider places the discharge to skilled nursing home order set.

The use of technology not only can help with better patient outcomes, increase patient satisfaction, it can also help institutions reach meaningful use criteria. Acute care settings can also increase reimbursement through MU, decrease the cost for readmission of the patient and redundant tests for the patient (Coleman & Berenson, 2004; Coleman, et al., 2006). The increased communication through the use of technology helps to support patient centered care (Reynolds, 2009).