The important role nurses play in care transition and reducing readmissions

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires that transitional care processes are under constant evaluation.

Nurses are the linchpin in the coordination of patient care, and thus are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand a great deal more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend to the patient high-value care beyond organizational boundaries.

Nurses create transitional care plans by compiling all the pertinent patient information and creating instructions to be followed. Then they share the plan in detail with all members of the new care team so that the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition of care is communication during the handoff process.

What to communicate and when

The goal of the handoff is to safely transfer the patient from one care setting to another (or to discharge the patient from the hospital completely) by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and either the new team of clinicians or the family prepares them in such a way that they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and especially in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

Many times, nurses on the receiving team care for patients for whom they lack pertinent health data. For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay extra close attention to medication communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences.

However, defective handoffs are also known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

 

The role of secure communications in your clinical integration strategy

If you could take one solution with you on your journey to clinical integration, what would it be?

Clinical integration is the unification of healthcare data, services and coordination across acute, outpatient and post-acute care. It portrays an environment where waste and inefficiency are all but eliminated from healthcare communications, costs decrease and care improves. It’s the future of medicine.

You wouldn’t be far off course if your first thought was to rely heavily on the EHR to support your clinical integration strategy. While the EHR is a valuable tool for sharing patient information within hospital systems and broader care networks, it lacks a fundamental quality that bridges the gaps between Meaningful Use and true clinical integration.

Fully realized clinical integration can only occur when the barriers of communication have been broken down, and interdisciplinary clinicians can accurately and reliably coordinate care in real time across organizational and geographical boundaries. As with most things related to healthcare communication and the sharing of information across disparate networks, securing those communications has been and will continue to be a primary focus for healthcare IT leaders. In an environment where healthcare organizations are driving toward an end-goal of clinical integration, enabling secure communications alone just isn’t enough.

To achieve clinical integration, clinicians need a solution that enables immediate, accurate, reliable and secure communications.

Immediacy in healthcare communication

Real-time communication is a crucial element of delivering high-value care. In the most critical emergencies, every second counts. The time that clinicians waste identifying the right on-call care team member to contact, and then trying to reach that person, can quite literally be the difference between life and death. Even in non-emergent situations, early detection and treatment are well-known effective preventers of worsening conditions.

Yet it’s all too common for inefficient and broken communication workflows to create time-consuming hurdles for clinicians to clear—sometimes even to just begin the conversation.

Clinically integrated settings approach clinician-to-clinician communication with a sense of real-time urgency. That’s not to say that every message should be sent with an emergency status, just that the process of identifying the provider you need to connect to and the delivery of that message should be seamless and immediate.

Reaching the right care team member on the first attempt should be an important metric for all hospital systems. To keep performance numbers high in this area, you must ensure clinicians always know exactly whom to contact for any given medical issue.

However, most clinicians today initiate time-sensitive contact to the broader care team by thumbing through a lengthy paper-based on-call schedule, making a call, and then waiting to receive a response.

Real-time clinical communication and collaboration tools immediately deliver secure communications, and even allow the clinician initiating the communication to see in real time when messages are delivered and read.

Contact accuracy

Reaching providers on the first attempt is important, but it’s just as important to reach the right provider—the one who can act on the medical issue at that moment—via his or her preferred method of contact.

It’s not uncommon for providers to have a different preferred contact medium for every variance of their schedule. And it’s not uncommon for those schedules to change at a moment’s notice. Yet many hospitals, in both small and large systems, only print the schedule and patient assignment lists once per day.

Clinicians in this setting have no way of knowing if they are accurately reaching out to the right providers via the right contact method. Manually producing a list of whom to contact and how is a process riddled with opportunity for inefficiency and inaccuracy.

Dynamic Intelligent Routing™ eliminates those opportunities for communication breakdown. A distinct capability of PerfectServe, Dynamic Intelligent Routing analyzes workflows, call schedules and contact preferences, enabling clinicians to reach the right person at the right time with just the tap of a button.

Reliable communication workflows

If your clinicians depend on inaccurate call schedules or outdated, cumbersome processes to drive clinical communications, your communication workflow isn’t reliable.

When clinicians can immediately contact the care team member they need via that provider’s preferred contact method, communication workflows become reliable and trustworthy, which leads to high adoption and improved patient care, no matter the care setting.

From improved care coordination to reduced costs

Inefficient communication workflows not only interfere with the realization of clinical integration, but also they inflate healthcare costs. For example, if a radiologist identifies a critical result in an outpatient test, the radiologist needs to contact the patient’s PCP so action can be taken right away. If the communication is not immediate, accurate or reliable, the process breaks down and the delay could result in medical complications for the patient that end up costing more to treat.

Moving a patient safely through the admissions, treatment, discharge and post-acute care processes requires a tremendous amount of coordination, good communication and a sound clinical integration strategy. The tools you use to support that communication and collaboration will play an important role in your success.