Better Care Across the Continuum

Falling Off the Cliff – The Need for Real-Time Communications in Care Transitions

I am proud to be a member of The Dementia Action Alliance, an eclectic group of individuals and organizations in long-term care dedicated to figuring out how we can deliver person-centered dementia care. Guess what? There is not a hospital in the Alliance. It puzzles me when I know care transitions are critically important.

Today, when a patient leaves the hospital, he/she literally falls off Closeup of a lonely senior man lost in thought , looking awaya cliff into a sea of options that they are unprepared for and know little about. In long-term care, we have a cacophony, a discordant mixture of services:

• Aging in Place

• Tele-health

• Retirement Communities


• Adult Day Care

• Assisted Living

• Skilled Nursing

• Home Health

• Hospice

We already struggle to engage patients in the hospital setting. Take the perspective of healthcare lawyer and family caregiver Kathy Kenyon who said this in testimony to the Institute of Medicine’s Committee on Family Caregiving for Older Adults.

“In my experience, one unfortunate unintended consequence of the current culture in healthcare is a type of medical error, which I call a ‘failure to heed or engage caregiver error.’ It’s a subset of the larger ‘failure to heed or engage the patient error.’ However, the standardized formats for identifying errors and harm in healthcare do not capture failure to engage or heed patients or caregivers. Is caregiver engagement a question on patient satisfaction surveys? Until we start looking for errors, harm and dissatisfaction caused by the failure to engage or heed caregivers, we lack evidence that might spur change.”

When we get it wrong on the hospital side, things often spiral out of control. People leave without the right discharge planning, go to a skilled nursing facility or rehabilitation center and end up back in the hospital.

Patient Experience and Patient Safety

A review of 55 studies by Cooley Dickinson Health Care found that there were:
“Consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs.”

The literature review went on to say that these findings: “Support the argument that the three dimensions of quality should be looked at as a group and not in isolation. Clinicians should resist sidelining patient experience as too subjective and mood-oriented, divorced from the ‘real’ clinical work of measuring safety and effectiveness.” recognizes the important role that communication plays in improving the patient experience, the quality of care and ultimately creating better outcomes. Kenyon’s testimony and clinical evidence clearly shows the correlation between communication and safe, quality care.

This is not a point to be taken lightly and in fact if there was one place to start in helping our patients/residents, it is educating all providers about this relationship.

That might start bridging the gap, set the stage for better communications among clinicians across the continuum, and set the stage for better communications between providers and patients/ family caregivers.

New Times, New Roles

Some have seized opportunities in bridging care gaps. Witness the rise of care advocates and geriatric care managers as professions. And yes, patient-family advisory councils have sprung up in hospitals.

Many of these are well meaning. Still there is a constant scramble to coordinate care with disjointed information, EMRs that do not communicate with each other, and retrospective data that often is too late to act upon.

New Technologies, New Possibilities

In their white paper, “Customer Experience Innovation Demystified,” Forrester states that successful organizations “create new types of interactions and/or significantly change the quality of interactions” as they drive long-term differentiation. It takes the organization from a “find and fix” mindset to one that asks “What if?” more often.

Meaningful Use Stage 3 requires providers to adopt customer engagement technologies to improve outcomes and HCAHPs. There is momentum gathering regarding the critical importance of engaging patients at the time of care.

In his book, Service Fanatics, Jim Merlino, past Chief Experience Officer for the Cleveland Clinic and now with Press Ganey said, “Verbatim and anecdotal data are very powerful when evaluated thoughtfully, used in the context of the local environment and pooled with other data.”

There are some real-time solutions out there like YORN. The problem is not the cost or technical ability to implement them. It is cultural. Often introducing new initiatives around patient/resident experience is met by staff as “one more thing to do” or “big brother watching.” These solutions are neither.

Better patient/family caregiver communication, when heeded, can lead to better safety and quality. The better you know a resident and/or patient the better caregiver you become. And when you consider that the experience of care IS the marketing for your organization, well, it gives you one more reason to pay attention.

Anthony Cirillo, FACHE Anthony is president of The Aging Experience. He helps organizations craft experiences and seize opportunities the mature marketplace. He helps family caregivers thrive and individuals make educated aging decisions. A consultant and professional speaker, Anthony is a monthly contributor on The Charlotte Today program, the expert in Senior Care, an executive board member of CCAL, and a member of the Dementia Action Alliance. In his home community, he participates in Huntersville CARES, a dementia-friendly community initiative, and is a board member of the Lake Norman Family Health Clinic. As someone who helped launch the patient experience movement, Anthony has a unique ability to envision the future state of health care, see solutions before others see problems and formulate answers before people understand the question. He has been called innovative, inventive, original and resourceful. He provides logical support for futuristic thinking and makes difficult to understand ideas easier for people to comprehend. Anthony can connect the dots in healthcare. CEOs retain him for big- picture thinking.

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