As an influx of seniors with rising acuities threatens to overwhelm senior living communities, clear communication about residents and medications is more crucial than ever. Where are the barriers coming from, and how can we overcome them?
Few can dispute the fact that information is the most valuable currency in business. Critical decisions rely on its accuracy. In healthcare, lives depend on it.
In spite of all of the tools at their disposal today, senior living providers face communication obstacles at every turn.
Mounting workforce shortages mean many run the risk of under-trained staff performing clinical procedures with incomplete information, or overworked employees dispensing the wrong medications. And in many cases, too much information communicated innocently by unsecured cell phones or emails can end up in the wrong hands, often with dire consequences.
The sheer volume of information creates greater opportunity for problems.
Few stakeholders experience the chaos more than the long-term and assisted living care pharmacy, which must deal with inputs and outputs from physicians, nursing home directors, discharge planners and caregivers – not to mention senior residents and their family members. The stakes are even higher when dealing with Alzheimer’s patients and memory care residents.
“From an operations standpoint, navigating all the communication methods to the pharmacy is complex and, at times, more information, more data equates to more room for error,” observes one Southeastern pharmacy general manager.
And even as senior living providers find themselves in the age of mission-critical data sharing, communicating the wrong information or omitting critical data can and does happen. Faced with increased privacy concerns, even seasoned staff can sometimes err on the side of caution.
Over the past few years, greater attention than ever is being cast on the communication problems that have long plagued transitions to and from acute and post-acute care.
Hastily handled transitional care often means important decisions are either skipped or made in error because vital information fell through the cracks during handoffs. Incomplete or wrong information during transitions can result in unanticipated rehospitalizations, which in turn can hurt a facility’s or community’s Five Star rating and level of reimbursement.
The transition process is a symphony of concurrently moving parts including vital data recorded at discharge and admission, patient record documentation and various kinds of information exchanged among providers, patients and bedside caregivers.
A breakdown in any one of these processes can sometimes lead to a cascade of one bad decision after another.
According to Stratis Health, a nonprofit organization that promotes collaboration and innovation in health care quality and safety, poor communication during transitions can lead to confusion about the patient’s condition and appropriate care, duplicative tests, inconsistent patient monitoring, medication errors, delays in diagnosis and lack of follow-through on referrals.
Complicating matters is the fact that in many areas of the country, even the computers still aren’t communicating at an optimal level.
The problem is called interoperability – a condition in which distant computers and servers lack the ability to receive and process data in a meaningful way.
Interoperability allows information to be universally used among insurers, government, caregivers and residents. Not only is it essential for the electronic medical record to be read and shared, but interoperability improves productivity and staff workflow and reduces financial and clinical risk.
Problems occur when skilled nursing home EHR systems cannot communicate with hospitals and other entities, forcing people to rely on faxes and phone calls and emails. Such disconnects can mean offsite pharmacists or doctors could find the referring hospital never closed out records on their end, leaving them to wonder if the patient ever made it to the nursing home in the first place.
“You have no idea how much time it takes for us to tap into this spigot of information,” says one pharmacy executive. “It takes forever in technology speak. It’s not because of the challenges of technology. It’s just the bureaucracy. “
In short, communications in senior living today has never been more complex and consequential.
What causes these gaps and gaffes?
As we’ve seen, incomplete information can lead to a host of problems.
Discharge summaries provide one example. Stratis Health asserts that all too often, these important documents leave out critical bits of administrative and medical information such as a primary diagnosis, results of abnormal diagnostics, details about the hospital event, follow-up plans, whether laboratory results are pending, and patient or family/caregiver counseling.
It isn’t uncommon for a transferred patient to wait as long as eight to 12 hours to have their medication regimen restored, according to recent studies.
Indeed. According to the Institute for the Advancement of Senior Care (iAdvance), long-term care and assisted living facilities should be prepared to be at a communication disadvantage from the start. Nursing homes often accept patients with diagnoses that are incomplete or missing – often for days and even weeks. They also have virtually no control on deciding what information is shared and often find themselves admitting patients lacking key information, hindering their ability to fully understand their diagnoses, status, needed supplies, or how to even conduct meaningful conversations with other key providers.
Back in 2015, a panel of long-term care thought leaders at the National Association for the Support of Long Term Care annual meeting discussed the regulatory limits and challenges of identifying mission-critical data elements for admissions and discharges.
“As advancements are made in information technology, healthcare partners have the ability to exchange buckets of information, yet nursing home staff are often still lacking some of the information needed to provide the best care, to have the right supplies ready at admission and/or to communicate with key providers in the care chain,” an iAdvance summary of the meeting noted.
“Gathering and storing the data isn’t that hard to do,” said one CIO. “The hard part is identifying which data points are most valuable to share.”
The report also outlined the communication gaps that continue to dog acute and post-acute settings. “There’s still a big disconnect between the data-sharing capabilities of hospitals and those of long-term care,” said one rehab executive. “At first, we weren’t talking about exchanging data with outside partners. We couldn’t even talk to each other.”
Another root cause is the current workforce crisis in long-term and assisted living care.
High rates of turnover and the industry’s inability to attract the kinds of numbers and quality of people it needs to care for an unprecedented surge in new residents complicates communication problems.
“In all of these facilities, there are adequate policies and procedures in place. If they follow them, they’re 90 percent there,” says one pharmacy executive. “It’s when facilities aren’t training their staff well, or take on new and weekend staff and are too busy, they begin taking shortcuts. We see this every day. Ensuring staff are well versed in pharmacy policies and procedures is an ongoing issue.”
Even the most vetted and reliable information is of little use to an untrained eye. Consider the long heralded electronic health record.
“EHR hasn’t helped the staffing crisis,” the executive adds. “It’s just one more barrier for a new staff member to navigate. Overworked nurses or those staff who aren’t properly trained on the highly sophisticated system can make mistakes in communicating medication orders – mistakes that typically aren’t discovered unless the resident’s medications are managed by a pharmacy services provider.
Today, more providers than ever are collaborating on many levels: achieving economies of scale, demonstrating care models that improve outcomes, and discovering efficiencies in purchasing.
They all share one thing in common: Unfettered communication. The kind of communication that’s completely open and rich in quality information. Exploring these myriad relationships provide valuable lessons about the importance of transparency and trust, particularly among competitors.
Near the end of 2017, two of the country’s largest post-acute care providers announced a partnership to achieve higher quality and improve transitions. The new world of “value-based purchasing” was a mutual need to identify ways to provide the best care possible, agreed executives of Kindred Healthcare Inc. and Genesis HealthCare. Under the partnership arrangement, both would track data on discharges, readmissions, lengths of stay and other episodic information in order to create new quality standards and protocols for post-acute care.
PharMerica’s TransitionRx, a pre-admission referral program for nursing homes, provides a good example of how effective communications between caregivers can work. TransitionRx partners with hospital discharge planners and care coordinators, which in turn allows PharMerica to provide admission assessments, complete with medications and lower cost alternatives to review with the admitting physician, before or during the resident’s admission. The process allows skilled nursing facilities to make informed, lower cost decisions about patients’ care. In addition, PharMerica’s Discharge Rx ensures the continuity of medications once residents leave the facility.
Even regulators are beginning to recognize the need for more lucid communications of the “plain-English” variety.
Though many federal agencies have routinely sought regulatory feedback, one December 2018 request appeared to open the door to making one particularly onerous rule easier to obey.
The Department of Health and Human Services issued a formal request for information asking nursing homes, senior living and other providers to provide ideas to ease privacy restrictions. As reported, the agency was interested in finding better ways for the Health Insurance Portability and Accountability Act (HIPAA) to advance federal goals of promoting more coordinated care.
Hospitals and other provider groups apparently succeeded in convincing the agency that the privacy laws have prevented them from sharing information with nursing homes to deliver more value-based care.
While there is no magic bullet to improve communications, experts agree that an acceptance of its value and commitment to doing it well must be imbued in each facility’s workplace culture.
Sometimes the solutions are as simple as, well, talking. The more, the better.
As reported recently in McKnight’s Long-Term Care News, a group of providers from Care New England Health System — and several other institutions — have embarked on a five-year project based on the so-called “Conversation Nurse” model, which trains providers to discuss serious illnesses and care goals with patients, from hospital to skilled nursing facility and back to their home. The Institute for Healthcare Improvement provides many of the tools needed.
Participants were persuaded to take on the effort after a successful project in neighboring Rhode Island led to decreased hospital readmissions, higher hospice consults in SNFs and broadening the skills of clinical team members involved in an accountable care organization.
“We chose to use nurses due to alignment of the project’s goals with the nursing field’s strengths,” the participants wrote in a Health Affairs blog. “Nursing has a focus on education and communication, and we have found many nurses have a strong interest in these conversations.”
Clearing the way for important communications among senior living communities, hospitals and other providers takes a village, especially during care transitions. As a preferred pharmacy partner offering expert consultant pharmacists, ValueMed can help streamline communication processes and clarify medication management to reduce errors due to miscommunication. Contact us at ValueMed@PharMerica.com or 866-628-2583 to learn more.Download PDF