by Nicole Spatafora
Director, Programs, Performance Improvement Collaboratives


Providers know that the patient care transition has long been the hinge on which the patient’s outcome swings. They also know there are many points, both on the patient and provider sides of the care transition, which can alter its planned course. With the move to value-based care, health systems are constantly evaluating ways to improve these transitions.

During a recent webinar highlighting a Vizient performance improvement collaborative titled, “The Care Continuum from Acute Episode to Clinic,” I had the pleasure of introducing Beth Lanham, director of quality management, from Genesis Healthcare System. Their project focused on improving care transitions for their large COPD population. Three interesting strategies were presented that I think could be important to consider integrating into any process of care transition.  

Focus on one issue to improve impact

For millions of Americans, social and economic issues are getting in the way of receiving effective medical care. These issues, known as social determinants, are numerous and varied in their impact on communities across the country. Patient data is providing us new insights into the significance of various determinants on health care delivery, including:

  • Homelessness
  • Lack of transportation
  • Behavioral health needs
  • Medication affordability
  • Limited access to education or job training

Through its pilot programs with COPD patients, Genesis Healthcare learned they could positively impact care transitions by concentrating efforts on one social determinant. Their strategy addressed a lack of transportation by obtaining funding for patient transportation to and from appointments.

Emphasis on this one determinant can reduce readmissions and return visits to the ED, enable better management of co-morbid conditions and improved medication adherence, as well as facilitate continued follow-up care with patients’ primary care physicians.

Yet, a lack of transportation nationwide causes some 3.6 million patients annually to miss medical appointments, according to an article in Modern Healthcare. New online platforms, such as Circulation and Roundtrip, are partnering with Lyft, Uber and others to transport patients in need.

Standardize baseline documentation

Technology is also playing a role in transitions of care. Here's a great example: there are 16 separate EHR platforms presently on the market. And, an EHR is additive to all of the other software programs that are currently operating within a health system. And, they likely aren’t effectively integrated.

In April, CMS renamed and refocused its EHR incentive programs to “Promoting Interoperability” programs. The long-range goal is one universal system but that’s still far into the future. In the interim, how many clicks does it take to get a good “picture” of your patient? It’s probably quite a few.

Doctors in the ED have noted they have to click-click-click through all of the various patient encounters in the EHR to try to put together a complete picture of the patient and their health. The solution from Genesis Healthcare involved adding a longitudinal, baseline overview of the patient view to the top left corner of the EHR so it was easily located.

In the left column of the baseline overview, they included past visit information. In the middle, they listed lab results and dates. In the right column, they included a problem list and medications. The consistent location and standardized data types allowed providers to grasp a patient’s baseline status much faster than before.

Develop custom smart phrases

Another enhancement to the EHR was the addition of “smart phrases," or “dot phrases,” as they’re sometimes called. Each phrase begins with a dot, such as “.HPROBL,” and it’s intended to streamline charting. This smart phrase links to a predetermined list of active Hospital PROBLems and pulls all of the relevant data into one view.

For the COPD project at Genesis Healthcare that means physicians could immediately see what the patient’s Sp02 percentage is, whether or not they’re on home oxygen, whether they have limitations to their activities of daily living and what medications they’re on.

With few exceptions, patient outcomes today hinge on positive transitions of patient care. The reality of value-based reimbursement drives this shifting paradigm. Hospitals and health systems can better support patients through strategies that are designed to accomplish optimum care transitions.

Targeting a single social determinant, standardizing baseline documentation, and developing custom smart phrases are the three care transition strategies that Genesis Healthcare implemented to transition patients from the acute care setting to the ambulatory setting, and that shifted patient outcomes in a positive direction.

The webinar noted above was part of a three-part series. To learn more about how to drive outcomes, reveal opportunities and empower action, check out the other two webinars:.

About the author. Nicole Spatafora is director, programs in the Performance Improvement Collaboratives for Vizient. She brings to her role more than 20 years of experience in ambulatory care, physician alignment and performance improvement, as well as physician practice and revenue cycle management in community and academic settings. Spatafora works with clinical, operational and clinical leaders to address critical health care performance issues that support increased quality of care, lower costs and greater efficiency.

Published: June 13, 2018