Last year, my grandmother became ill and spent 10 days in the local ICU. We brought in all her medications at the beginning of her stay to ensure she had what she needed and to inform the care team of her health and medication history. Thankfully, after a few days in the ICU, my grandmother improved enough to be discharged from the hospital and sent to a skilled nursing facility (SNF) for continued care.
Over a period of days at the facility, her appetite decreased, and she started to feel progressively worse. She began to experience an acute sickness with symptoms unrelated to the primary reason for which she was receiving care. Something was definitely amiss.
At this point, a few healthcare professionals in our family put on their clinician hats to advocate for her and help figure out why she was feeling poorly. After asking a series of questions about her care, it was determined that she had not been administered some critical medication for a few days. The missing medication helped manage other peripheral conditions and was vital to her overall well-being.
We found out that communication about her active medications didn’t occur between her primary care physician and the hospital, thus it didn’t trickle down to the SNF. It took multiple nurses over many hours to make phone calls and chase faxes between different providers to piece together an accurate list of my grandmother’s active medications. While we were thankful for their efforts to get her back on track, I would describe the experience as unsettling.
After a brief time, my grandmother was discharged and sent home with orders to receive home health care. We were confident that because the home health services were provided under the SNFs operations, her new providers would be on the same page.
Except, they weren’t.
At the first home visit, it took a well-qualified nurse more than 90 minutes to completely reconcile my grandmother’s current, old and missing medications. Over an hour and a half to make sure records were correct from her health history. Valuable time that could have been used to care for her was wasted.
As her granddaughter and a health professional, it boggled my mind how often this was happening. Seeing it happen once is one thing, but the lack of communication between multiple settings was and continues to be concerning. For whatever reason, the communication just simply didn’t happen.
The numbers are interesting, for sure. It’s been estimated that more than 40 percent of medication errors stems from lack of reconciliation as individuals travel across care settings, with 20 percent of these errors causing a harmful situation.  Also considering that 30 percent of post-acute patients are on eight or more important than ever.  As clinicians, it’s a valuable tool in our arsenal to help avoid a potential disaster.
Luckily, my 84-year-old grandmother is sharp as a tack and can effectively communicate how she’s feeling. With loved ones with backgrounds in healthcare to help advocate for her, she had a lot in her favor to help identify the disconnects in her care.
What about those who don’t have that? What about the individuals who are navigating their health journey alone or whose caregivers don’t know the right questions to ask?
It’s our responsibility to align as providers across the entire healthcare continuum, from behavioral health to primary to acute to post-acute and everything in between. By granting providers complete access to health information, they’re then able to deliver appropriate and timely care.
Connectivity and the seamless, secure flow of health data is key. An individual’s complete health record – including behavioral health, physical health and social determinants - should travel with them through an entire episode of care. Connections to programs like Carequality or local health information exchanges and prescription drug monitoring programs can make a world of difference for everyone involved. A simple query of networks like these can put volumes of relevant and timely information at a provider’s fingertips.
Timely access of information also creates efficiencies by reducing redundant or unnecessary testing and procedures. It eliminates the need to chase data by phone calls or faxes along with duplicate data entry, saving time on administrative tasks. This frees up time to focus on what clinicians have been called to do - care for those who need them most.
From a provider perspective, there must be a focus on smooth transitions of care. These transitions can be achieved by implementing a people-focused approach to discharge planning. Specifically, including a thorough medication reconciliation regardless of electronic health record (EHR) and a strategy to connect the interdisciplinary care team to the individual and their caregiver(s) and family. Bottom line, communication must be clear for everyone involved to create the most successful environment for recovery.
Ask yourself, “Does patient health information flow freely to and from my facility?” If the answer is no, examine your EHR and its capability to connect to others. Lack of information can be detrimental, leading to rehospitalizations or something even worse.
At the end of the day, it’s about breaking down silos between care settings, connecting and communicating with each other and owning our part in an individual’s healthcare journey. In my grandmother’s case, she was lucky to have loved ones who were in-the-know, but not everyone has that kind of support system. It’s up to us, as providers, to do our part to create opportunity to reach the best health outcomes for individuals to live their healthiest lives.
 Hughes, RG. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. https://www.ncbi.nlm.nih.gov/books/NBK2648/ April 2008.
 Leavitt Partners. Post-acute care (PAC) optimization in a value-based economy. https://leavittpartners.com/whitepaper/post-acute-care-pac-optimization-in-a-value-based-economy-bridging-the-gap-between-hospital-and-home/ May 2017.
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