as care transitions are more critical, good tech is essential

Technology has created a new era of care transition that is empowering the post-acute sector while creating a shared sense of responsibility when it comes to the ultimate care of the patient.

But although care transition has been a focus for years, it has gained greater prominence due to recent pressures of readmission penalties and prospective payment models that require providers to assume more risk, said Tom Sullivan, MD, chief strategic officer for Rockville, Maryland-based DrFirst.

"The big risk for errors is from acute care to where the patient goes next – rehab, home or nursing home," Sullivan said. "Discharge plans are so complex now, but if they aren't followed closely, the patient will get readmitted, and now there are penalties. If you don't get the transition right and the readmission could have been avoided, it will cost the system more money."

Information technology is enabling providers at each care site to receive, evaluate, monitor, and, yes, nag patients to promote their health and safety. But minding the patient's health status remotely through various tech is key to preventing costly hospital readmissions, industry analysts say.

DrFirst is contributing to the care transitions process by taking advantage of the nearly universal move to mobile solutions. Its Backline product allows for chat via text or voice and includes a patient-centered chat function as well. Because the Office of the National Coordinator for Health IT has called for test and lab results in addition to an exchange of summaries, the DrFirst tool uses the mobile platform to enable exchanges beyond the desktop, Sullivan said.

One major challenge in maintaining the continuity of care during a patient transition is smoothing over the gaps where patients can fall through, said Nan Hou, RN, managing editor for Los Angeles-based Zynx Health.

"The most common gap between acute and post-acute care is hospital-to-home," Hou said. "The main problem is communication between the transferring provider and receiving provider – one-third of them don't receive documents from the hospital and only 12 percent to 34 percent of discharge summaries reach the care teams."

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