5 reasons why communication breaks down during care transitions

Office-based primary care physicians (PCPs) often bear the brunt of responsibility for ensuring their patients avoid readmission after transitioning from a hospital or post-acute care facility. In many cases, however, preventable readmissions are a result of communication breakdowns between the hospital and the physicians in the community.

With so many hospitals and health systems still relying on faxes and phone calls to convey discharge information, it’s a wonder why breakdowns don’t happen more often. As a result, many hospitals and health systems are implementing integrated, mobile clinical communication platforms that allow office-based physicians to use secure smartphone-based apps to collaborate and share data in real time.

The following are five common reasons communication breaks down during care transitions and how clinical communication platforms can help solve these issues.

Patients often do not understand discharge instructions. When office-based physicians don’t have access to the most current patient information, patients receive conflicting instructions and may wait too long to schedule a post-discharge checkup at your practice. With an integrated communication platform, care teams, including the PCP, can have group text discussions about a single patient. Data is also instantly accessible through the smartphone to ensure that safe and effective care is continued after the patient returns home.

Poor ADT sharing. A study conducted at the School of Medicine of the University of Colorado recently found that, in some cases, PCPs were unaware their patients had been hospitalized at all.

Automated Admission, Discharge and Transfer (ADT) alerts are eliminating this dangerous handoff gap. Utilizing industry-standard HL7 protocol, ADT alerts notify PCPs in real time that their patients have been admitted to or discharged from the hospital. The front office staff can contact patients to schedule follow-up appointments and help remove any barriers that would prevent them from adhering to treatment regimens.

Missing contact information. The hospital electronic health record (EHR) may not have an updated PCP contact, or it may just have the name of the practice. As a result, the hospitalist or attending physician won’t know who to contact about post-discharge care. In one study, as few as 12 percent of PCPs actually received their patient’s discharge summaries. Unifying PCPs on a single clinical communications platform opens the communication channel in an efficient, asynchronous way that ensures patients receive the necessary follow-up to keep them on the path to healing and away from a readmission.

Lack of context in data. The EHR data and discharge report don’t always include the whole story about the care provided in the hospital or information that may influence the patient’s post-charge care. A patient’s family struggling to understand or help their family member adhere to the care plan, for example, is an important consideration. Notifying your physicians or clinical support staff that the patient’s family may need extra educational support with care instructions could be shared through secure one-on-one text messages from the attending physician, but it may not be included in a standard discharge summary.

Delayed consults. Breakdowns happen when transitioning to the hospital, too. For example, a patient in the emergency room may not be able to provide all the required information to the attending physician and nurses, or the attending may have questions for your physicians. Pagers are inefficient, requiring your physicians or a medical assistant to return a call and then wait until the attending is available. An integrated communication platform would notify your physicians’ smartphone of a consult request and include full patient details, so your physicians could review their assessment before returning the call, making the consult more efficient.

While it is ideal for all providers to share the same clinical communication platform, PCPs who have not yet implemented the system could be included in one-on-one or care-team consultations. These physicians would receive a secure link so they can communicate and easily collaborate with others on the platform.

This is certainly not an exhaustive list, but it’s clear how leveraging technology that nearly all physicians use every day-smartphones-combined with an integrated, clinical communication platform could eliminate many communication breakdowns. The result instead would be safer care transitions, more coordinated care, and better outcomes across the board.

Brad Brooks is the co-founder and chief executive officer of TigerConnect.