Embedding evidence-based medicine into transitions of care

A colleague of mine who is an outpatient care manager shared with me that the value of population health technology became clear for her after one day getting a real-time alert that one of her patients was in the ED. She called the ED and was told that the patient’s blood glucose levels were extremely high, and the ED nurse thought the patient should be admitted. However, the care manager informed the nurse that the patient’s numbers were actually the patient baseline, and recommended that the patient not be admitted, which saved an unnecessary admission. The outpatient care manager was able to devise and implement an effective plan of care to address a variety of contributing barriers to care, and the patient outcome was improved.

This story is about taking the right action, in the right timeframe, in the right care setting. The following are a few best practices to think about as you develop your strategy.

Facilitate access to primary care

Coordinated care is a proven value for high-risk patients, however, it is often a challenge for patients to access primary care soon after being discharged. Some organizations have found it effective to enroll high-risk patients into a Patient Centered Medical Home (PCMH) as a standard practice to get them better connected to primary care, a care coordinator, as well as to other community resources. Another approach is to partner closely with primary care clinics and even embed a care manager, a transition focused mid-level practitioner or social worker into the clinic to specifically serve high risk transitions patients.


Standardize interdisciplinary care

When multiple levels of clinicians partner effectively with defined pathways and shared information, it’s amazing to see the impact. For example, psychiatrists and social workers going to a PCP's office to speak to patients. Pharmacists calling physicians to say a prescription ordered is far more expensive than other options. Home health that directs patients back to lower acuity centers if needed, and works with patients to prevent unnecessary ED stays.  Population health is truly a team sport and technology can help support transparency making patients more confident in a team-based delivery model.


Embed practices into workflows

After establishing your care protocols and pathways, care management tools can help ensure they are followed consistently. Intelligent plans of care can have pathways embedded in the patient care plan, assuring that steps are not missed. Role-based tasking can help a team of clinicians take the right steps, in the right sequence, all while working at top-of-license. As mentioned in the story earlier, alerts can let the appropriate care team member know when a patient has a change in status, or whether an ED visit, observation stay or inpatient admission has occurred. Lastly, as it is common for patients to be managed in multiple EMRs, technology can play a big role in streamlining medication review and in overall information sharing by aggregating data from multiple EMRs.


Improving transitions of care, supports long term success in advancing quality, patient experience of care as well as managing the cost of care. Organizations should be thinking about strategies for scaling, risk stratification, solving for social determinants and reducing variations in care. Wherever your organization is today, if you focus on meeting patients where they are at and guiding them through what is a complex healthcare system, you will have succeeded in a foundational strategy for long term success.  


About the Author:  As Vice President, Care Transformation at Caradigm, Vicki Harter leads a team of clinicians responsible for helping customers and prospects optimize care workflows needed for population health management. Vicki is a clinician with a passion and vision for health information technology as an essential tool to advance population health.