Transition of Care

Improving the transition of care process

Transition of care management has never been more significant. The need to decrease avoidable days and readmissions has put increased pressure on case managers to find the best post-acute care setting for their patients in the least amount of time.

And with skilled nursing facilities (SNF), home health agencies (HHA), long-term care hospitals (LTCH), rehab, psychiatric hospitals all competing for referrals it is difficult to find the most appropriate care setting. All this comes at a time when aging baby boomers are pressuring the healthcare system as never before. Clearly, good transition of care will continue to grow in importance, in order to ensure the best patient outcomes and optimum use of healthcare resources.

Challenges in a typical transition of care

Faced with a need to select follow-up care after an acute stay, in accordance with patient choice regulations, patients and their families are often confused and under time constraints when transition of care is being planned. Information about options is sometimes limited or difficult for patients to fully understand. Hospital case managers are also hindered by lack of comprehensive information on post-acute providers, as well as lack of time to best match patient needs and preferences with qualified facilities. Post-acute providers can also feel pressure in the referral acceptance process to make decisions without adequate information.

As the number of patients needing follow-up care continue to rise, having a solid, efficient transition of care process is more important than ever.

How to “scale up” to match the growing number of patients

Becoming more efficient and better equipped with information will improve the outcome for you and your patient. Take a look: where in your care transition process could improvements take place?

  • Are you bogged down with a mostly manual process which forces you to play phone tag, including checking and re-checking availabilities?
  • Is vital patient information being sent via non-secured email and fax?
  • Are patients given a “standard” list of post-acute providers, including those that are not a match for patients’ needs and do not have availability?

Every situation is unique, of course, and the issues will vary depending on the patient and provider. But one way to “scale up” your process – allowing you to take on more patients without adding more tasks or staff – is through automating key steps in the transition of care. New software is all about saving time, which is a good place to start your improvements.

5 ways technology can improve your transition of care process

1. Eligibility, required skills, and provider availability get validated before patient selects a provider.
Technology can help! ABILITY Network has an easy-to-install insurance verification software which allows you to check a patient’s eligibility almost immediately. You can further hone the list by electronically matching up the patient’s clinical needs with the skills of post-acute providers. Presenting patients with a list of providers who are appropriate by clinical, insurance, and resource availability can eliminate re-work, confusion and frustration – and vastly improve the patient experience.

2. Referrals can be posted to multiple providers at once, and appropriate providers can indicate interest electronically. Once a patient selects her preferences, the acute provider can post the referral opportunity to the appropriate post-acute providers. There’s no need to waste time phoning back and forth to match available, appropriate providers with the patient.

3. Once a selected post-acute provider accepts the referral, the acute provider gets a prompt to confirm the referral online. Details are confirmed using a HIPAA-secure text messaging feature. No need for a round of phone tag.

4. All documentation is attached to the online referral. Secure care transition software keeps patient information HIPAA-compliant. Get rid of paper, faxing, and shredding – saving time, reducing cost, AND ensuring patient confidentiality.

5. Manage all admissions through a customizable dashboard. The ABILITY care transition software builds a database and gives you one place, online, to keep on top of every patient transition – in process, pending, or approved.