Managing Transitions of Care
PatientShare offers secure, private, seamless health data exchange for post-acute transitions of care
The Problem
Care transitions between hospitals, post-acute care facilities, and home nursing care are common for individuals with chronic conditions, following surgery, or an acute health event. Coordination is critical when one of these patients transitions from one care location to another. But without reliable sharing of patient health data, care coordination can be fragmented and lead to poor health outcomes, increased burdens, and increased costs.
Lack of data interoperability—especially for community organizations, like SNFs (Skilled Nursing Facilities)—is a key barrier to improving care coordination. As a result, care providers in facilities downstream from the hospital may not have accurate information to inform care. Patients may leave the hospital with poorly defined care goals or uncommunicated care goals, leading to poorer quality treatment in care facilities. That might even lead to unnecessary hospital readmissions and their associated penalties.
- At transitions of care, providers receive clinical information after the patient's appointment 50% of the time, including vital information on medication and medical equipment needs.
- 68% of specialists received no information from primary care teams before patients arrived.
- 1-in-4 Medicare patients discharged from acute care went to an SNF. Of those, a further 1-in-4 will be readmitted to the hospital within 30 days.
- Post-acute care accounted for $60 billion in Medicare spending in 2015.
Lack of interoperability between facilities leads to messy patient hand-offs, risks poorer patient health outcomes, and financial penalties for providers. For example, they might be at increased risk of readmission penalties, malpractice suits, and orders for duplicate tests and treatment without reliable care coordination.
Solution: Improve Interoperability During Care Transitions with PatientShare
PatientShare improves communication between patients and providers and interoperability among care teams. In addition, access to longitudinal health information across health care entities and systems will improve operating efficiency, the quality of care these facilities provide, and health outcomes, while reducing the risk of malpractice claims and CMS penalties.
PatientShare and the FHIR APIs on which it runs deliver seamless access to clinical data for patients and care teams throughout care transitions.
Health data can be made available at the patient's destination care facility, whether a SNF, an ambulatory care facility, inpatient rehabilitation facility (IRF), acute care facility, or home and community-based services (HCBS). In addition, the same critical information can be made available to the patient's family, caregivers, and anyone else in their support system who needs access. When the patient's data follows the patient, accurate data is always available when and where it matters most.
Unlike other systems, those requesting access to the patient's health data through PatientShare do not need to be a member of a predefined network. Instead, we have enabled seamless, dynamic access across the whole health ecosystem using FHIR APIs. That enables the formation of ad hoc networks of choice and need.