Home > Education : Transitions Between Care Settings: Challenges
Transitions Between Care Settings
Identification and Analysis of Major Challenges
The report groups major challenges into three categories: market challenges, operational challenges, and accountability challenges.
Market Challenges
Competitive environment. Hospitals compete with each other for patients, as do physicians, and sometimes the competition can get in the way of good communication during the patient transition.
Another competitive factor is the increased use of hospitalists, and potential care management issues between the oncologist and the hospitalist. Patient management issues and disagreements were reported. Often, the oncologist was not notified that his or her patient had been admitted. Cases of failure to notify the oncologist of hospitalization were more likely when the oncologist’s patient was admitted for something other than cancer.
There also tends to be high turnover rate among hospitalists. A working relationship between an oncology group and an oncologist can be upended if the hospitalist leaves and is replaced. In working with the hospitalist, the challenge, then, is for the oncologist and hospitalist to reach agreement with oncology group practices on co-management and to restore an effective working relationship as hospitalist turnover occurs.
Costs and reimbursement. Effective management of the patient transition generally means standardized procedures carried out by dedicated personnel along a continuum of care. Yet the cost of managing the transition is not built into the reimbursement structure, and so is generally taken on as an add-on by the hospital. Funding the professionals to help manage the transition (whether through home visits or follow-up phone calls) is often a challenge as reimbursements are tightened. Some practices have found that billing efficiencies and patient satisfaction gains from use of a financial counselor and patient navigator outweigh the associated personnel costs.
Another challenge identified in the study is that the patient, once home, is in a new reimbursement environment. Prescriptions and chemotherapy that may have been covered completely in the hospital may not be covered as well at home, potentially leading to treatment interruption or prescriptions going unfilled. Part of the transition task is to help the patient identify the drugs needed (changes may have occurred as a result of the hospitalization) and how they can be paid for, whether by the patient out-of-pocket, through insurance, or by some other means.
Operational Challenges
Software and its limits. The start-up phase that has brought the EHR into the hospital and into the oncology group practice is almost complete for most hospitals. Almost all hospitals and oncology groups have EHR systems. However, these systems present several challenges for the patient transition. The principal challenges appear to be: 1) issues with system interoperability and standardization; 2) hospital EHR systems without oncology components that are useful; and 3) full capability use of EHR systems by hospital and group staff and physicians.
One common problem involves electronic transfer of usable data between the hospital and the oncology group EHR systems. At the time of the survey, many medical groups with separate systems were either in the process of developing the hospital interface or planning it for the near future. The challenge was even greater for medical groups admitting patients to several hospitals. At present, the general approach for most oncologists is to gain access to the hospital’s EHR from the group offices, and access the patient’s hospital records for review in this way. When oncologists admit to multiple hospitals, this could mean requiring physicians and/or their clinical staff to learn two or three different EHR systems.
Limited integration of data between systems also lends itself to incomplete transfer of all information in the medical record.
A more general approach involves community-wide agreements on standards and system communication. But reaching such a community-wide solution can present technical as well as political challenges. New federal standards for certifying EHR systems, standards defining what "meaningful use" of electronic health information means in clinical practice, and federal funding for regional health IT organizations that assist in EHR adoption, will likely accelerate interoperability at the community level in the coming years.
A second challenge is that the hospital EHR rarely includes an oncology component, and when it does, that component receives poor ratings from the clinical staff, so they often do not use it. Bringing the functionality of the oncology group's EHR to the hospital's inpatient EHR is apparently a strong technical challenge that has been successfully implemented in only a few hospitals with which we spoke over the course of this project.
A third challenge is that while the EHR may be in place, the technology and software are complex and still evolving. Staff may not fully understand how to fully use the system, leading potentially to gaps in documentation of care. Furthermore, many medical record systems remain a mix of paper and electronic records: In some cases, when an EHR was present in the hospital, the discharge summary was still faxed to the physician office. The EHR systems are not necessarily user-friendly to physicians and their staffs who wish to access them from external group offices or from home.
Medication reconciliation. With the adoption of computerized prescription order entry systems, the issues of medication reconciliation have taken a solid step forward. Most hospitals and medical groups appear to have fairly effective medication reconciliation procedures in place. As mentioned previously, the challenge is to take the extra confirmatory step when needed to call the patient's physician or pharmacist to assess which drugs the patient is taking at the time of entry into the hospital or community practice.
Measuring performance. One of the dilemmas in improving the transition process is that very few hospitals or groups know how well their patient transition process is working. If there is a follow-up survey conducted by the hospital, it typically covers the hospital experience itself and not the transition. Even then, the more typical survey method is a mailed questionnaire (a low-cost approach) and responses may not be representative of more complex discharges.
Measurement of 30-day readmission rates or follow-up phone calls to systematically determine transition problems are not often part of the transition process. A key challenge, then, is for organizations to upgrade and expand their post-care surveys and analysis of those surveys to address the transition. While some organizations had transition programs in place, few of them are using survey and measurement tools to analyze those processes for quality improvement.
If hospitals and oncology groups don’t know how well the transition is going, it becomes difficult to develop systems, policies and strategies for improving their performance.
Accountability Challenges
The patient at home. As the patient is discharged, a wide range of follow-up care scenarios must be addressed and managed during the transition. While our surveys focused on the first post-discharge outpatient oncology visit as a key transition event, the open-ended questions in the surveys revealed that a bigger challenge is to identify and obtain services for the full range of the cancer patient's needs. Cancer patients may require help with managing pain, with mobility and function, and with their emotional state. Terminally ill cancer patients may benefit from hospice or palliative care services. Many of the needs can be identified during the discharge process, but some only emerge when the patient reaches home and directly faces the new reality. The transition challenge is to identify and manage the patient and family needs at a time and in a location in which neither system (hospital nor oncology group) has control, accountability or responsibility.
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