Three Ways Technology is Optimizing Patient Transitions

October 7, 2020 Melissa Bagnoli

Skilled nursing facilities (SNF) have long understood and benefited from the value of data collection to make informed decisions. The challenge many face is not having the data they need, causing medication errors and readmissions among other things.

The keys to success? Collecting the right data and making it actionable.

The addition of COVID-19 to the mix has added unprecedented and worse, unanticipated obstacles for care teams to ensure a complete picture of patients’ medical history. These challenges have made it difficult to even apply available data and use it effectively.

For SNFs to solve these challenges during the pandemic and long after, creating a centralized method to make data-driven decisions is one of the biggest and most important investments. By applying technology to better understand the patient journey, these tools can accelerate integrations and create actionable insights that optimize quality care.

Here are three steps you can follow:

Step 1: Ensure a Complete Care Plan

Instituting an accurate care plan requires a patient’s complete medical history prior to admission. If a piece of information is missing during the transition phase (especially common for patients with a COVID-19 diagnosis), it can lead to future issues.

Medication reconciliation (MedRec) is a key factor in attaining a complete picture of a patient’s health data, of which a patient’s list of medications must be shared across each new care setting. Nearly 20 percent of patients experience negative health events within three weeks of discharge, the leading cause of which is adverse drug reactions. Also, nearly three-quarters of these health events are preventable with proper medication reconciliation at discharge.  

Step 2: Gain Total Patient Visibility Before Admission

The majority of readmissions happen within the first 24 hours of a patient’s transfer to a SNF, reinforcing the need to ensure visibility into the patient’s information from the start. After all, staff members across their respective departments need to be able to make timely decisions.

First, the admissions department must determine if they have space to admit each new patient, gathering and assessing the patient’s information in order to communicate their decisions. In tandem, nursing teams conduct a mini-assessment to ensure that they have the right staff to care for each patient, based on their respective health and care requirements. Finally, the billing department can then check to ensure the patient’s payer will support the care they need, confirming their eligibility for the stay and determining how much it will cost to care for that patient.

Widespread visibility into patient data isn’t just important for delivering the best care. It’s – also critical for SNFs’ day-to-day operations.

Step 3: Enable Data Sharing with Partners

While a holistic view of patients’ information across your entire SNF is the goal, the ability to share data seamlessly with partner organizations presents its own set of challenges. SNFs and hospitals must be able to share and easily access each other’s patient data during care transitions. Improved interoperability strengthens the partnership between SNFs and their referring hospitals, preventing missed pieces during care transitions through greater access to and transparency around data.

Get What You Need

SNFs want data. They see its value and know its benefits. But what they really need is to collect the right data and the ability to easily transform it into decision-making power. By following these steps, SNFs can improve their transitions of care, increase internal communication and advance external partner relationships. These benefits are essential for operating efficiently and delivering the best care, despite the unique set of complications presented by COVID-19.

To learn how to implement these 3 steps in your facility, check out our guide, “3-Step Guide to an Effective Admission Process”.


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