It takes a (digital) village
Staying informed is vital to establishing continuity of care and a patient-centered care model. Fewer independent doctors have hospital privileges and are making rounds, meaning hospitalists are left to care for seniors who are admitted to the hospital. This means the tending doctor does not know if or when the patient previously visited the emergency department, whether the patient was admitted to a hospital, or if the patient lives in a SNF. The doctor is now also at the mercy of the patient or patient’s family to provide records following the hospital visit or admission.
That presents a health risk—and an opportunity for improvement. Here are five strategies to bolster the role information sharing for better care coordination:
Ask for updates. Communication is critical, and increasingly so, as healthcare continues to operate in individual silos. For each patient visit, PCPs and their staff should actively request updates from the patient, family, caregiver, or healthcare surrogate on recent changes in patient medication and history, including hospital visits and use of telemedicine or telehealth services.
Build relationships with hospitalists and SNFs. Unfortunately, PCPs may not always receive vital updates from specialists, SNFs, or family members. To the best of your ability, engage hospitalists and area SNFs about patient activity and how to improve information sharing.
Add EHR alerts. Not all practices or providers share electronic health records (EHRs). If your practice uses EHRs, inquire with your technology provider about prompts or the ability to be notified of patient status updates, particularly after visits to specialists or hospital admissions.
It’s also important to note that long-term care providers were not incentivized in the same manner as hospitals and other providers to adopt EHRs through HITECH Act, so their adoption of and adjustment to electronic delivery of records is still in its infancy compared to other healthcare sectors. You may need to devise additional strategies to stay abreast of patient status updates.
Encourage your patients to keep you updated. Send patients home with literature after each visit encouraging patients and their families to keep you informed. Establish your expectations regarding sharing of patient information—be it a visit to the emergency department, walk-in clinic, specialist, move to a SNF, or a change in medication. Explain what you want to know, why you want to know it, and how this information will ultimately help the patient. It can’t be underestimated how informed PCPs can anticipate needs, elevate care, and reduce bounce back into the acute care or rehabilitation system.
Avoid complacency. Make continuity of care an internal gold standard. With the growing use of accountable care organizations, PCPs will see demands for quality, efficiency, and outcomes rise. The sharing of information must be that gold standard at your practice. Collaboration and sharing of information will certainly result in an increase in these metrics.
PCPs who care for older patients can avoid the communications chasm and better prepare for the tsunami, silver or otherwise, by examining the whole patient and communicating with the patient and other healthcare providers.
Gregg Clavijo-Hopper is COO and senior vice president of post-acute services at Greystone Health, a Florida-based provider of owner-operator skilled nursing facilities and home health agencies offering a full continuum of care for both patients and referral sources.