Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. 3.1. Evidence Base for Health Information Exchange to Support Care Coordination During Transitions and Instances of Shared Care

10/29/2013

This section examines the evidence base around care coordination to support transitions in care and instances of shared care including the impact of failures of care coordination, and the potential role of HIE interventions and programs to support care coordination and care transitions.

Failures of Care Coordination During Transitions and Shared Care

Failures of care coordination and failure to transfer key information often occur during care transition and handovers.1617293031 Examples include failure to transfer the results of medical tests and important information from the medical record, little or no information from referring primary care providers, and inadequate or missing discharge summaries.32 Failure to make available complete, accurate, and timely information (such as medication-related information) at times of transitions contributes to adverse events, threatens safety and quality of care, and increases costs.1417182526333435363738 Some of these errors could likely be avoided with timely and accurate information exchange.

Failures of care coordination also often result in avoidable hospitalizations and readmissions and undermine patient care.353940 Hospitals' readmission rates are high and costly, and many of these readmissions are preventable.1921414243 There is a national public policy focus on reducing avoidable hospitalizations and readmissions, and this goal is used for both quality measurement and performance-based incentives for Medicare and other insurance programs.41 Hospital readmission rates vary across types of LTPAC/LTSS providers, with SNFs and home health care agencies typically having the highest rates of inpatient readmissions.13

Adverse events such as medication errors occur frequently during care transfers and during instances of shared care. Many medication errors can be prevented or ameliorated with simple strategies that include exchanging relevant patient information. The lack of communication between doctors, hospitals, and community pharmacies has been found to be the major cause of medication errors.35 To address this increased risk of medication errors during care transfers, the Joint Commission and the Institute for Healthcare Improvement have provided national leadership to support medication reconciliation at each point of transfer. Medication reconciliation refers to the process of reviewing the patient's complete medication schedule at the time of admission, transfer, and discharge and comparing it with the schedule being considered for the new setting of care.3044 It also refers to the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. Medication errors may occur when care is shared by multiple physicians and other providers because these clinicians may be unaware of the patient's complete medication list or health status.45

Evidence Base for HIE to Support Care Coordination

Care coordination is enhanced through expedited patient information flow, which reduces duplication of care services such as tests or procedures and the likelihood of conflicting care plans12131415161718 and medical errors,24 and can result in cost savings.394647 The exchange of clinical information is especially important during care transition, when patients are transferred from one health setting to another. In addition, HIE improves population health through electronic surveillance, more accurate and timely clinical research, and more effective consumer and patient engagement.48 While no single intervention implemented alone, or bundle of interventions, appears to be associated with reduced risks of rehospitalizations,49 many successful interventions involve a strong information exchange component.4150

For example, Ouslander et al. evaluated the INTERACT tool--a quality improvement (QI) intervention that includes a set of tools and strategies designed to assist SNF staff in early identification, assessment, communication, and documentation about changes in resident status (See Appendix A for more information on this program). INTERACT has a number of information exchange components such as transfer documents with a checklist of recommended items. Nursing facilities using INTERACT had lower self-reported hospitalization rates after implementing the tool; however, the investigators were not able to determine which components were most strongly associated with changes in hospitalization rates.51

Many other care transition models, programs, initiatives, and best practices (e.g., ONC Challenge Grants, Partnership for Patients, Medicaid Transformation Grants) have an information exchange component, exchanging key patient information, including information to support care transitions and medication reconciliation and management.7365253545556 Some of these programs and initiatives are briefly described below (see Appendix A for more details). Further, some of these models, programs, and initiatives encourage the use of HIT to support HIE across care settings.525758

CMS produced a "Roadmap to Better Care Transitions and Fewer Readmissions"36 focusing primarily on discharges from acute care hospitals. The Roadmap identifies elements of good transitions, including some that involve HIE-standardized, accurate, and timely communication and information exchange between the transferring and receiving provider. The Roadmap also identifies the type of information that should be exchanged at times of transitions in care. The conclusions in Section 5 compares these elements to the actual types of HIE information that were found to be exchanged. Other elements of good transitions include collaboration across health and LTPAC providers and other services and supports; patient and/or caregiver training; patient-centered care plans; procurement and timely delivery of durable medical equipment (DME); and ensuring the sending provider maintains responsibility for patient care until the receiving clinician or organization confirms the transfer and assumes responsibility.

Promising components and interventions to reduce hospital readmissions are identified in white papers on care coordination.4159 A list of these components and interventions is provided in Appendix D. There are many models for organizing care coordination and the care coordination model used is less significant to success than a close working relationship between providers, care coordinators, and patients, facilitated by communication and sharing of information.59

The promising components are consistent with evidence-based approaches promoted by Medicare's QI organizations, the Institute for Healthcare Improvement, and AHRQ as being areas that can reduce avoidable readmissions. The components include:60

  • Intensive post-discharge followup -- Placing frequent telephone calls, as well as sending encouragement and reminders to keep appointments.

  • Enhancing care coordination at the interfaces between care settings by ameliorating process breakdowns of information -- Seamlessly transferring patient information from inpatient care team to post-discharge care team.

  • Addressing medication discrepancies -- Helping patients understand how to use medications and warning signs that would warrant an emergency call to the physician.

  • Providing coaching and patient education -- Providing patients comprehensive information instructions on self-care and medication management and equipping patients with digital tools to document care and communicate with the care team.

  • Identifying issues, receiving actionable data from the home, and intervening early in the home to decrease acute care visits and exposure to preventable readmissions.


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