How did they accomplish these goals? According to the Transitions of Care Survey Summary Report, recently released by The Health Care Improvement Foundation, hospitals participating in the 18-month Preventing Avoidable Episodes (PAVE) Project improved upon strategies that enhance transitions of care and prevent hospital readmissions. Those strategies could not have happened without electronic health records (EHRs) and related health information technology tools.
More than 90% of hospitals are now evaluating or implementing a screening tool that identifies patients at high risk for readmission and boosts patient education. For example, the number of hospitals that give patients checklists and other reminders has nearly doubled, and all hospitals now provide patients with detailed discharge plans.
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"The project highlighted the need to improve the timeliness and the manner in which patient discharge information is transmitted to other providers, especially the primary care providers. The hospitals involved in the project are actively addressing this," Patricia Yurchick, senior director, Quality Partnership & Initiatives at the Health Care Improvement Foundation, told InformationWeek Healthcare.
"In addition, we have begun discussions with other key stakeholders to develop a regional health information organization (that will govern a regional health information exchange) to help improve these communications across provider settings."
However, while technology can enhance care coordination, the project did provide an example where technology has been tried but the results fall short of expectations.
According to Yurchick, the project included a workgroup focused on personal health records (PHRs). The members conducted pilot studies that involved developing PHRs with patients and then assessing whether these patients actually maintained their PHRs and referred to them at their doctors' visits.
"The results of the pilot showed that the patients who would benefit the most from a PHR were incapable or unwilling to maintain them. As a result, the group took a step back and developed a booklet for heart failure patients initially that attempts to engage the patient in the management of his or her condition through daily weight tracking," Yurchick observed. "The booklet is being finalized and will be piloted over the next few months. If successful, it will be shared among the regional providers for use."
As part of PAVE, hospitals also have worked to coordinate and share patient information across the continuum of care, so that physicians, nursing homes, home health agencies, and insurers have the information needed to improve patient care and avoid readmissions.
Among the effective strategies hospitals have adopted, according to the study:
-- Almost all hospitals now coordinate with patients while they are still in the hospital to make follow-up physician appointments; more hospitals are coordinating follow-up testing.
-- Nearly 50% of hospitals send patients' discharge summaries to patients' primary care physicians; more than 40% of hospitals are evaluating and implementing ways to share summaries with primary care physicians.
-- Nurses at nearly 60% of hospitals are doing nurse-to-nurse handoffs when discharge patients transition to nursing homes or other care settings; the remaining hospitals are evaluating or implementing such handoffs.
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