Hospitals and health systems have become the epicenter for much of the funding and focus of the healthcare industry. And where this attention is no doubt warranted given the critical role that these facilities and providers play in our communities, it’s short-sighted of our collective focus to ignore what happens after someone leaves the hospital. Because, ideally, they do…leave the hospital. When cost containment, quality initiatives, and patient well-being hinge around the ability to prevent readmission, we simply have to take steps toward not only bridging the gap between post-acute care and hospitals, but toward cultivating a connected community of providers to manage transitions of care like a boss!

Post-Acute Providers Play a Pivotal Role in Transitions of Care from the Hospital

If you’ve been around for long at all, then you know how strongly we feel that post-acute providers should not be required to jump through so many hoops to connect with the greater care team. But given the sheer volume of different technologies that exist to accommodate all the unique documentation needs (and budgets) of post-acute providers, it can seem dubious that the gap can be closed and true collaboration achieved. Where we can move the needle, though, is in easing up on strict standards and costly interfaces, and instead focus on how we establish (or discover) secure, simple tunnels of communication between all kinds of providers, especially when they share the common and urgent goal to move the patient toward wellness.

Skilled Nursing and Home Health Providers are great examples of members of the care team that play a huge role in not only the transition of care process beyond the hospital, but also in the longer-term prognosis of the patient. (Let’s never forget that the goal isn’t just streamlined tech…there are people behind these problems that are worth fighting for.) Where SNFs provide a solid landing spot post-admission, these providers are often operating blind due to delayed, outdated, or altogether lost patient documentation. And keep in mind, the very nature of their patient mix is vulnerable, so this is where tight processes and optimal communication are vital. Millions of dollars in cost savings are up for grabs when we streamline transitions in care from hospital to skilled nursing, even in just the referral management process alone.

Referral Management Is the Key to Smooth Transitions and Ongoing Provider Communication

Speaking of referral management… The administrative process can be a barrier or a boon to the care experience, and referral management is an area that still feels very painful in a lot of care settings, hindering provider collaboration, frustrating patients and caregivers, and potentially sabotaging outcomes.

Kno2 was proud to be part of an interoperability showcase that highlighted the potential of the 360 Exchange (“360X”) Protocol for managing and tracking referrals between providers. Where we see such potential with solutions like 360X is that it’s tapping into technological infrastructure that already exists! So, it’s not another product, another vendor, and another invoice. It’s a promising trend to see movement within existing avenues, finally bringing to life many of the communication channels available via robust EHRs used in hospitals and health systems that have yet to be turned on or tapped into to create connected care teams without costly integrations or fancy tools.

When you consider that a connected provider network can not only close the gap immediately following a transition in care from the hospital, but also continue its reach into Physical Therapy, Emergency Medical Services, Pain Management, DME and Home Health, and more…the vision of actual coordinated care doesn’t seem so lofty.