Exploring Barriers to Care Continuity During Transitions

Thumbnail Image
Issue Date
Waller, William
Cardinal, Cortney
Casucci, Sabrina
Hewner, Sharon
Continuum of care , Health facilities--Discharge planning , Medical records--Data processing
The discharge process from a hospital requires multiple health care disciplines working in concert to safely transition patients from the acute care setting. During this transition, gaps in care continuity can occur for multiple reasons, including a lack of home support, inadequate understanding of care needed at home, errors in medication reconciliation, and follow up care needs that go unmet. Purpose and Aims of Study: The purpose of this study was to determine the current methods hospitals employ to move patients safely through the hospital and the discharge process. Patients that are at a high risk for readmission are more vulnerable to gaps that occur during care transitions. As such, the focus of the study was on these patients. Methods: Observational data was collected from discharge planners, patient care coordinators, social workers, bedside nurses, physicians, pharmacists, and multiple interdisciplinary teams. The information obtained from these observations include workflow, communication, documentation, information collection, and information sharing related to care transitions. Using qualitative analyses, process maps were generated. Results: A three-phase, high-level process map was generated with a focus on the relation between two teams, the clinical team and discharge team. Detailed process maps were created for each of the three main phases: emergency department, inpatient care, and discharge process. The process maps visually represent the current workflow and communication patterns that occur and improvement opportunities were identified. Conclusions: Preliminary observations include the fact that the clinical team functions largely without input from the discharge team. In contrast, the discharge team requires extensive input from the clinical team and utilizes a large amount of time and energy looking for this requisite input. Our preliminary findings indicated there are substantial improvement opportunities in the communication between the clinical team and the discharge team. Additionally, the use of Health Information Technology (HIT) can be utilized to guide the intensity of care planning.