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Creating Better Transitions of Care for Patients and Providers

Stan is an 86-year-old veteran who has been living with Parkison’s Disease for 14 years. He is lying on a gurney, repetitively calling for Lillian, his wife, because he is in pain from a fall and cannot process all the movement happening around him in the emergency department (ED). Medical staff ask a myriad of questions about his current needs, medications, community supports, and the like—Stan just keeps calling for Lillian, unable to even articulate the experience of pain he is in.

Stan was sent from a skilled nursing facility (SNF) that called the hospital where the emergency medical services (EMS) were taking Stan and sent an envelope with instructions. However, that hospital was put on divert, and when Stan arrived at a different ED, the envelope was misplaced as the medical team worked diligently on addressing Stan’s immediate care needs.

When Lillian arrived, the staff was relieved for Stan to have her comfort and to get some background on his care, only to discover that Lillian was living with cognitive deficits and was unable to answer their questions. Unable to glean insight into Stan’s care needs, the ED had to proceed with a comprehensive work up and admission to ensure Stan (and Lillian’s) safety as they pieced together his situation.

Hospital staff didn’t realize Stan actually had excellent support from a care coordinator assigned by his long-time primary care provider. His Medicare Advantage Plan had assigned a utilization management case manager. Stan also had an intake case manager from Medicaid to help process his enrollment to access much needed custodial care services. Being transferred from a SNF, Stan also had a resident care manager (RCM) and social services director (SSD) supporting his care.

In total, Stan and Lillian had three social workers, two registered nurses, and a physician involved in his care and not one of them was able to help the ED staff because none of them had any way of knowing where Stan was.

Had the clinical care team been able to see their mutual relationships to Stan they could have collaborated on his transitions of care. Primary care providers foster strong longitudinal relationships with their patients and frequently have deep insight into patient and family needs. Had the utilization case manager, Medicaid intake case manager, and SNF team known, they could have shared pertinent information through intentional handoffs across the care continuum, allowing for the care coordinator to keep tabs on Stan and intervene before his needs became acute. And Stan may have experienced decreased anxiety and stress if his primary care coordinator would have been able to be there with him in the unfamiliar hospital setting. 

Better care transitions are beneficial for both patients and their providers. Using Collective’s platform, the Portland Clinic was able to overhaul its Transitional Care Management (TCM) workflows. In doing so, the Portland Clinic was able to increase TCM coding rates by 33 percent—resulting in a 30 percent increase in revenue and better patient outcomes.

Kate Dowd Esser, BSW, MA
Senior Clinical Solutions Lead