Three main areas or systems will need to be addressed in order to support accountable care objectives; care transition, coordination of evidence-based care and consistent reporting and communication.
Care Transition and Coordination of Evidence-Based Care
As the patient transitions from one care setting to another, it is important to address those areas that are often a concern, such as summary of care provided by previous setting, medications, follow-up with primary care provider, and maintaining a comprehensive record.
There are several care transition models available in the public domain. Contact the Quality Improvement Organization in your State for guidance, or access the Institute for Health Improvement for information about the State Action on Avoidable Rehospitalizations (STAAR) initiative.
Being aware of the high-cost areas of care, identifying risk factors applicable to the individual patient, and working with the physician, the patient and the family to establish a reasonable and evidence-based plan of care will be imperative. Evidence-based approaches to care are available for numerous disease processes and co-morbidities from public sources.
Consistent Reporting and Communication
Clear documentation of every evaluation of the patient, each communication with the physician and other providers, each communication with the patient and/or a family member, all tests, measures, etc. should be included in the patient health record. With comprehensive documentation, reporting of outcomes, trends, etc. can be gathered. Utilization of an electronic health record solution for all documentation will allow for data mining of information both at the patient level and at the population level.
The sharing of information between providers is imperative to make certain that every provider has the same information from which to make decisions regarding patient care. Whether the information is shared electronically through continuity of care documentation included in the HITSP C32 (National Institute of Standards and Technology, March 2009) or on paper utilizing a standardized form of communication such as SBAR (Situation, Background, Assessment, Recommendation) (Institute for Healthcare Improvement) and/or discharge summaries, the overarching factor is to communicate and coordinate.