How to Solve the Challenege of Care Transitions

Posted January 26, 2015

The care received during an emergency visit is crucially important to a patient’s eventual health outcome. But one of the biggest predictors of a patient’s eventual health outcome is the experience they have once they leave the hospital.

If this is so crucial to health outcomes and the patient experience, the question remains: how can we better connect and support a patient once they’ve left the hospital?

1. Successful transitions start with continuity of care across the medical neighborhood.

The medical neighborhood can be defined as all the care received by any given patient. From resources to actual patient/provider encounters, this includes:

  • The primary care physician and support team;
  • Specialty providers;
  • Community health workers, pharmacists, and even in-home care support.

Adherence to a physician’s orders can be greatly affected by the information and resources that are passed along and communicated by these various points of care.

When patients have an integrated experience across this care continuum, it is a win-win for providers and patients, with patients being able to more readily make value-based care choices. All care team members have extensive context about a patient, potential gaps in treatment are closed, and providers have the ability to send consistent messages in regards to treatment.

2. Successful transitions require support that can be delivered at the right time (and the right place).

Physicians agree that many patients may not be able to tell you what—or why—they have been prescribed during any given visit. The reality of when a patient leaves a medical center is that they may not fully understand their diagnosis or corresponding treatment.

Or, they may not be as equipped to self-manage their health as they were prior to their hospital visit.

But we do know that successful transitions happen when patients feel equipped with this key information. A successful transition also requires a patient to feel confident about carrying out the behaviors being asked of them.

Treating Patients More Effectively, Without Adding Care Workers of Facilities

We may call it patient engagement, but fostering this ability to self-care is highly reliant on the environment in which someone lives each day. This environment—which is often in the home where a person wants to continue to live independently—should be one that includes monitoring and support.

The caregiver for a MedaCheck user shares the following story:

“Until a few months ago, my 88 year old, visually impaired mother lived on her own and was able to care for herself pretty well. She filled her medication box each week and took her meds correctly almost all the time. Then, she suffered a stroke and developed memory problems. She began missing doses regularly and worried that she was going to make a mistake with her pills. We were convinced that it was time to start looking at assisted living or other options.”

But because of MedaCheck, she was able to preserve her ability to live independently.

“Mom almost never misses taking her meds on time [now]. If she does forget for some reason, she receives a call from MedaCheck to remind her. If she doesn’t answer the phone, they text me to let me know something’s not right. Because she is responding to her ‘pill clock,’ I know she’s alright even when I can’t call her.”

When we can better manage the common barriers that come with transition of care, we can improve adherence, the patient experience, and ultimately health outcomes.