Can you help me find the very best examples of how innovative use of technology can improve care transitions?
Reducing preventable readmissions to the hospital is an important goal for many health systems. The United States has an 18% rate of hospital readmissions within 30 days of discharge. Many of these hospital readmissions are preventable simply by improving care coordination and paying close attention to what happens during a care transition. According to Medicare data, over half of readmitted patients received no care or follow-up in the 30 days after hospitalization. [Citation: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. Apr 2, 2009;360(14):1418-1428.] After a hospital stay, patients often receive care that is fragmented and uncoordinated. This results in many problems both for the patient and the caregiver. Lack of care coordination drives up the cost of care and leads to errors in care delivery. Poor handling of care transitions also can result in expensive visits to the emergency room, even if there is no readmission to the hospital.
Studies by Coleman, Naylor, and others suggest that interventions targeted toward postacute care transitions can reduce hospital readmission rates by one-third. Many experiments are being conducted across the country to try out different approaches to improving the care transitions process. We need to raise the visibility on some of the promising approaches that might offer near-term benefit if they were more widely-known.
I'm looking for examples of innovative technology and protocols that have the potential to improve care transitions in the near-term in real care systems. I hope you will let me know if you have a working application or well-developed concept paper that deserves wider exposure. The technology interventions I'm looking for will focus on one or more of the following factors:
- Streamlining discharge planning to include better assessment of care transitions issues, with risk assessment for readmission
- Improving communication between clinicians and patients to improve care transitions
- Providing direct patient support during the transition from one care environment to another
- Improving patient self-management to reduce the need for readmission or a visit to the emergency room
- Better medication reconciliation and adherence
- Reducing the cost of patient monitoring and following up with patients after discharge
I'm particularly interested in looking at technology innovations in those categories where some outcome data is available showing improvement on any or all of these outcome variables:
- Rate of hospital readmission
- Emergency room utilization
- Patient and caregiver satisfaction
- Overall cost of care
The Center for Technology and Aging has produced a very good technology overview for this subject that will help you get started. You can download "Technologies for Improving Post-Acute Care Transitions Position Paper" directly from techandaging.org (September 2010, Discussion Draft http://www.techandaging.org/PACTdraftPositionPaper.pdf).
Growth House developed the Care Transitions Search Widget, a free search utility that you can install on your own web site to help your users locate information about improving care transitions and reducing hospital readmissions. The widget is a simple example of how technology can play a role in improving the care transitions process.