Healthy aging

Navigating the Levels of Post-Acute Care Part 2

older woman and middle age man sitting on couch talking

In part one of this series, you learned about the different levels of post-acute (PAC) care. Now that you have a basic understanding of the PAC provider types, let’s focus on the importance of interoperability and accessibility of health information across the care continuum, with a particular emphasis on the PAC settings.

In our scenario from the first article, your mother had a stroke with residual memory impairment and an inability to ambulate independently. Then your mother was transferred to a local inpatient rehabilitation facility (IRF) so we will pick up from there. Shortly after she arrives at the IRF, you meet with the team for an update on her status and to review the plan of care for her stay. As the IRF team discusses your mother’s information and medical status, you are struck by how much information is incorrect or missing. You ask the IRF team if they have received your mother’s records from the hospital. They explain that they receive a discharge packet of information, but do not have full access to her electronic medical records (EMR). You are perplexed by this news. Doesn’t medical information travel from one place to another? In a perfect world, it would, and there would be real-time electronic communication. However, there are many reasons why this doesn’t happen consistently within the care continuum, such as:

  • Various EMR systems can differ across the care settings and may not “talk” to each other
  • Additional costs required to ensure integration
  • Not all healthcare providers have the infrastructure to promote this exchange, including a robust State Health Information Exchange (HIE) or other mechanism to share information available for access across care settings
  • Lack of understanding on the importance for this exchange
  • Staffing issues in healthcare, including shortages and turnovers

The lack of information sharing due to lack of interoperability can lead to patient and family frustration and can even be the source of medical errors. 

Continuing with our scenario, your mother will not only have one transition of care from the hospital to the IRF but  another from the IRF to an area home health agency (HHA). This transition requires more education and research for you and your mother on questions like:

  • What is home health and what services do they provide?
  • What are the requirements of receiving home health, such as being homebound and what that really entails?
  • What home services are covered by her insurance?
  • Which HHAs service the area where she would be staying as a part of her recovery?
  • Which HHA has the best outcomes and where can you find that information?
  • How to determine whether she can go home by herself with home health support or if she, instead, needs to stay at your house during her recovery.
  • How to determine whether supplemental private duty nursing is needed and what that would cost.

As in the first article, this research was conducted through online searches and review of the information that an IRF provided. Some facilities, like the IRF your mother is in, use electronic platforms to assist patients and their families to make an informed choice. These platforms range from the  basic that allow you to type in an address and search by provider type in that area, to more complex platforms that allow you to list all the care needs,  your choice of geographic location, which payers each agency accepts, and even their current capacity. Some platforms are even set up for the referral a patient to another provider. For example, in this case, the IRF could send electronic referrals to the HHAs to review after you select a provider(s), or before you choose one, to help guide you to those willing or have the capacity to accept  a patient.

Since the HHA chosen for your mother’s care is not a facility-based care provider, there is the added need to make sure that the HHA schedules a date and time to start her care and that it occurs in a timely manner. The best practice is to start care within two days of discharge from an inpatient facility to help prevent things such as readmission, hospitalization, emergency department (ED) visit and medication errors. It is important to ensure that  after a first visit, subsequent home health visits occur. Navigating the health system, which isn’t always easy, is an added worry for you and your mother. 

All of these transitions between the different levels of care increase the risk of important pieces of information being missed. For instance, did her primary care physician (PCP) include the medications she was on prior to her stroke? Should the old medications continue? Do you follow the new prescriptions from the hospital or the list from the IRF? Do you wait until the HHA starts tomorrow, or do you call her PCP to ask for guidance? Without the seamless exchange and availability of health information enabled by interoperability between the different levels of care, including with the PCP, critical care needs may be negatively impacted. An opportunity to improve communication across the care continuum is to transition from antiquated practices, such as faxing,  to e-faxing or open communication though electronic platforms, or even directly through the EMR.

The focus on true interoperability is not coming fast enough across all levels of healthcare. On a positive note, health systems and hospitals have a small number of EMR platforms to choose from, so the reduction in systems should make interoperability easier to achieve. However, in the PAC setting, there are even more EMR platforms that could delay interoperability further. This is due to PAC providers ranging in size, from small entities to large organizations, with varying levels of resources to pay for information technology (IT) infrastructure and the personnel to assist with IT support.

Another issue beyond interoperability is the lack of knowledge on how to work with various EMRs. PAC providers need to not only understand how to navigate their own EMR, but also the EMR of their referral source, if they are lucky enough to have access to view them for the referred patients. A resource that may be available is the Health Information Exchanges (HIE). HIEs allow a provider or even a payer (with proper consent) to pull medical records from any provider that is participating in the exchange. This allows them to have access to real-time medical information for the patient(s) to whom they are providing care.

In our scenario, your mother was able to return and remain safely in her home after home health services were initiated. This, however, isn’t always the case. Some people transition between several levels of care, including a hospital stay to long-term acute care hospital (LTACH) to IRF to skilled nursing facility (SNF) to HHA, or back and forth between these levels of care. These repeated transitions in care settings make the handoff between providers and communication across the care continuum extremely important. Factors like discharge instructions, continuation of patient/family education, access of test results, and even upcoming appointments are beneficial for the providers across care settings. 

The access to health information through technology and robust interoperability of systems can play a significant role in improving care transitions. Great progress is being made, but as healthcare IT professionals, we need to continue to push for solutions that support some of our most vulnerable patients as they navigate the entire spectrum of care.