Key Takeaways

  • Transitions of care carry unique risks of harm that can drain resources.
  • Insufficient discharge information and incomplete hand-offs to other providers are key contributors to failed transitions of care.
  • Digital health advancements can support successful transitions of care by streamlining care coordination and educating patients.
  • [CASE STUDY] Learn how one major medical center improved its postoperative ePRO collection.

I spent the last decade of my career in the hospital, at the bedside, striving to deliver the best care I possibly could. But when the IVs are removed and telemetry monitors are disconnected, a whole new journey begins for patients — one outside of hospital walls and where they’re mostly on their own. 

The truth is that the patient care journey extends far beyond hospital stays and doctor visits. Much of what goes into healing takes place at home or in other settings. So how do care teams support their patients’ well-being after they leave?

The traditional approach is to throw people at the problem. For a long time, I was in that camp — trying to squeeze every minute, every second of a 12-hour shift to ensure quality transitions and positive outcomes for my patients. But this strategy is truly unsustainable. As hospitals face one existential crisis after another (e.g., staffing shortages, diminishing resources, declining engagement), relying on staff volume alone for ensuring patient safety is just unrealistic. 

That’s why it’s crucial to understand how healthtech can support providers to simplify and improve transitions of care.

What are transitions of care — and what are some of the risks?

Simply put, transitions of care refer to supporting patients as they move from one setting to another in their care journey — such as during a hospital discharge, transfer to a rehab facility, or switch to at-home care. But conducting these changeovers presents inherent risks, raising the stakes to get things right for patients and providers alike.

Failed transitions of care can significantly harm patients. Research over the past decade suggests up to 49% of patients experience at least one medical error after discharge, and one in five patients discharged from the hospital suffers an adverse event. 

But failed transitions create a vicious cycle that affects care teams, too. They result in an increased burden on care team members, higher utilization of limited resources, and further frustrations that the system will never change for the better. 

This haphazard loop ultimately diverts attention away from top-of-license care, potentially leading to more critical safety events, poorer patient-provider communication, and snowballing harm rates.

How can transitions of care be improved?

To get at the root of improving care transitions, we have to understand why problems arise in the first place. One common issue is incomplete discharge information. When patients aren’t given comprehensive and understandable instructions, they’re more likely to miss a medication, veer off a treatment plan, and even get readmitted for a new condition.

Another large contributor to failed transitions of care is incomplete hand-off to other providers. Patients experiencing nurse handoffs are 24% more likely to have a hospital readmission, and 21% more likely to have a hospital readmission within 30 days. 

Although a change in care setting presents several challenges, the most significant strategy for improving transitions of care is standardizing clear and thorough communication. And a recent study found communication interventions at the point of discharge are strongly associated with fewer readmissions, as well as better treatment adherence and patient satisfaction. 

Having comprehensive discharge conversations is a great first step — but patients forget over 50% of information discussed with providers. That’s why delivering consistent reminders and anticipatory guidance will help reinforce critical information at the moment a patient needs it the most.

How can digital healthcare help with transitions of care?

So how does healthcare leap beyond the discharge conversation to support successful transitions of care?

One effective answer is adopting an intelligent care enablement platform — scalable technology that supports both patients and care teams through complex clinical episodes to more efficiently deliver personalized, proactive, and coordinated care. Digital healthcare platforms that fall within this category can help by:

1. Streamlining care coordination

The right healthtech gives providers a longitudinal patient view, presenting them with a window into their patient’s history, their concerns, and which medical professionals have helped them. And advanced healthtech like Memora Health takes things to another level, giving clinicians the power to immediately view patient concerns and tag care teams — all in the same EHR-integrated application.

2. Automating care follow-up

Providers check in to remind people about medication refills, clinical reminders, and to assess how they’re doing. This is typically done manually — but, unfortunately, that’s a principal reason why follow-up gaps happen in the first place. Powerful digital health platforms can help your organization automate this aspect of care delivery, freeing up your clinicians to perform at the top of their license and ensuring every patient experiences high-touch support throughout their care journey.

Memora can help increase treatment adherence by 62%

3.  Educating patients

Providers make sincere efforts to prepare patients with everything they need to know to successfully shift care settings. But it doesn’t always stick. The best digital healthcare innovations actively educate patients throughout their care journeys so that people can get their questions answered quickly and accurately. Memora’s advanced natural language processing (NLP) can interpret user phrasing to automatically provide the right information or assist patients with next steps for addressing their inquiries.

4. Simplifying symptom management

It’s common for patients to report alarming symptoms after leaving the hospital. Traditionally, they’ve had to call their provider, endure long wait times to speak with a doctor, or even end up readmitting themselves out of worry. But digital health has the potential to address patient symptom questions without the need for a phone call or ER visit. Intelligent virtual health assistants can answer patient questions in real time, triage urgent requests to providers, and even pose helpful questions to probe deeper into reported concerns.

5. Improving remote patient monitoring

In a hospital setting, care teams continuously monitor their patients. But once someone exits the building, tracking their status gets more difficult. That’s why digital health platforms that reach patients where they are with SMS text are effective solutions for helping engage people away from the clinic. And the most forward-thinking technology moves beyond simple text reminders for appointments, actively checking in with patients to automatically report any issues and clear up miscommunication — all without providers having to answer portal messages.

Every care team faces unique challenges to coordinating successful transitions of care. But clear and thorough communication is at the heart of any ironclad strategy for helping patients land on their feet. And using the right digital health platform that simplifies, standardizes, and streamlines coordination is the way forward for health systems to get it right for every patient, every time. 

Find out more about conquering transitions of care.

Originally published March 20, 2023.