Tuesday, November 03 | Care Coordination, Post-Acute Care, Thought Leadership

Time to Improve Care Coordination? Start with Technology and Training

By Margaret Hart , Netsmart

As a writer at Netsmart, I’ve often enumerated the importance of making information accessible across care settings. The right technology gives clinicians and caregivers the ability to collaborate and coordinate, two capabilities that significantly improve both outcomes and patient experience. But, to be quite honest, I didn’t grasp the true significance of those statements until I was navigating the care landscape for my mother. 


Here is what lack of coordination and miscommunication looked like when I was on the patient side of communication. 


The patient and family perspective


When my mother entered assisted living, she had a few manageable, chronic ailments: slight mobility issues and occasional short-term memory lapses. But, overall, she was in good shape, especially considering her age. As she would say, laughing, “What do you expect? I’m 90 years old!” 


I switched her primary care to the doctor who regularly visited the facility, making it easier to coordinate her medications with staff. Her day-to-day caregivers were excellent, always pleasant, willing to answer my questions and help whenever asked. 


All went well for five years, until her memory lapses became more frequent. She was, as the floor supervisor put it, “confused, but pleasantly confused.” However, when she began trying to leave the facility without supervision, we had to transition her to a more secure floor. It was then, after this transition, that communication began to break down. 


Communication gaps during care transitions 


I asked she be tested for a urinary tract infection to eliminate a potential source of her confusion. Two weeks passed before I asked about the results, only to discover the request had not been passed along to the supervisor on her new floor. 


By the time the test was done, she was quite ill and had to be hospitalized. Looking back, I should have followed up sooner or contacted her doctor to be sure the test was done. But, with no previous issues with staff communication, I didn’t think it was necessary.  


During my mother’s hospitalization, I had a frank discussion with the hospitalist who offered advice on how to make an increasingly frail 95-year old as comfortable as possible. We agreed to stop two medications that had side effects and no longer offered significant benefits to someone her age. Mom recovered in a few days and moved to a skilled nursing facility (SNF) affiliated with the hospital to regain her strength.  


Medication reconciliation is a must


Upon admission, I made sure the SNF had correct records of all her information and medications and visited her every day to ensure all was going well. After two weeks of therapy, Mom was well enough to go back to assisted living. 


Unfortunately, the SNF discharged her with the medication list from when she was admitted to the hospital, rather than the updated one. The error wasn’t discovered until a few weeks later when she began experiencing the side effects we had been trying to avoid. 


How did it happen? I have no idea. I was following her care very closely. The SNF had an electronic health record (EHR) and received the correct medication list from the hospital. Regardless, something went off track during the discharge process between the SNF and assisted living. 


This was all quite frustrating because I know the staff members at the SNF and the assisted living facility were doing their best. Still, there were gaps in the technology, the training and the transition process that negatively impacted my mother’s comfort and health.  


A challenging juncture in the patient journey


It’s clear that the breakdowns occurred when Mom went from one care setting to another. Her transition from assisted living to acute care went smoothly, but the move from skilled nursing back to assisted living did not. Even the move within the assisted living facility was problematic due to the missed request for a UTI test, which resulted in hospitalization. 


My advice to patients and family members is to be hyper vigilant during transitions or care changes of any kind. Question everything and doublecheck everything. Be a pest, if necessary, be sure all information is present and correct. As someone deeply familiar with what could go wrong, I took all necessary steps to prevent mistakes. It still wasn’t enough.  


How to improve care coordination 


For SNFs, be sure staff members are fully trained on your technology. Work with your nursing staff and your technology provider to set up workflows and protocols for admission and discharge that will minimize errors. The correct medication list was in the EHR—I know because the nurse went over the list with me when my mother was admitted. Despite this, no one caught the mistake at discharge. 


For continuing care retirement communities and assisted living facilities, look into technology that creates a single record to document each resident’s medications, physician instructions, therapies and preferences. The technology should support information sharing wherever a resident goes, within your walls or to another facility. It’s unfair to ask staff members to rely on Post-it® notes, faxes or recollections to keep residents safe and healthy. Give them a system that helps them.


Finally, I want to emphasize that everyone in every care setting did their best for my mother. As the family member in charge of her care, I deeply appreciate the effort that went into keeping her healthy, happy and comfortable for so long. But there is room for improvement, and I believe training and technology can both go a long way to make care transitions smoother and safer.  


Meet the Author

Image of Margaret Heart, Netsmart Creative Writer
Margaret Hart · Netsmart


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