- As the healthcare industry continues its evolutions into value-based and patient-centered care by way of health IT, the American Hospital Association (AHA) has released several white papers highlighting the need for patient engagement and care coordination.
According to a recent press release, the AHA has released a new, comprehensive white paper connecting all of the key actions needed to make these patient-centered goals a reality.
The white paper, entitled Connecting the Dots Along the Care Continuum, explores four key concepts: patient and family care, team-based care, new and emerging healthcare models, and care coordination and transition management. Furthermore, AHA explains how health IT and EHR use is a key driver in improving quality care across the continuum.
Health IT is the Driver of Quality Care
In the white paper, AHA demonstrates how the burgeoning health IT market is the ultimate driver of quality care as it directly enables both patient engagement and care coordination, two of the primary tenets of care quality improvement.
“Technology is the common fiber that supports patient and family engagement; team-based care; new/emerging health care models; and care coordination and transition management as the field transforms from volume-based care to value-based care,” the AHA white paper explains.
Furthermore, AHA explains that continuous assessment of the growth of health IT and how it is affecting various care delivery methods is necessary for healthcare innovation.
Specifically, AHA addresses the importance of interoperability, explaining that it is key in effectively using health IT systems such as EHRs.
“Interoperable health information systems are key to configuring service delivery in new and emerging care coordination models. The EHR is an important tool to advance the quality of communication and information exchange across provider systems and to improve health outcomes,” AHA writes.
The EHR Incentive Programs and meaningful use are critical in facilitating widespread EHR adoption and interoperability, according to AHA. By incentivizing the adoption of these systems, they can be adopted by eventually all providers to help increase care coordination and patient engagement across the continuum.
“To be optimally effective, EHRs require broad adoption, practitioners must pay constant attention to data entry to minimize errors and care coordination patterns have to be reengineered to accommodate EHR usage,” AHA confirms.
Patient and Family Engagement
Patient and family engagement can be measured quantitatively by utilizing the patient activation measure, according to AHA. This measure examines the psychological and physiological connection a patient has to his or her healthcare and how this leads him or her to making better health decisions and to make future engagements.
Additionally, AHA explains that bedside care is critical, and must be adequately coordinated. One method for doing this is utilizing structured interdisciplinary bedside rounds (SIBRs), which reduces fragmentation of care.
During these SIBRs, all unit-based team members who are responsible for a patient visit him or her together each day. The team includes the attending physician, primary nurse and other health professionals, such as those working within pharmacy, social services or palliative care. The team cross-check perspectives and complete a quality-safety checklist with the patient, family and each other, then develop a shared care plan for the day and create a specific discharge plan.
Physicians can further increase quality care by utilizing care teams, and emphasizing a role-based rather than task-based mindset.
Furthermore, caregivers must recognize and understand one another’s roles in caregiving in order to effectively utilize the team model. One method by which this can occur is Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), which emphasizes team-based learning and care.
“The training program focuses on four competencies— leadership, situation monitoring, mutual support and communications—but goes beyond general health care team needs to include a set of tools for customizing the team performance based on the needs of the team,” the white paper says.
New and Emerging Healthcare Models
AHA explains that providers, especially primary care physicians, should be embracing new healthcare models, including ones that foster care coordination, the delivery of care during off hours, and the restructuring of the care-team model.
Various initiatives the deserve attention, AHA says, include the patient-centered medical home (PCMH), the accountable care organization (ACO), and the Health Home initiative.
Furthermore, clinician skill sets must expand with the growth of the above initiatives. Physicians can no longer be able to simply rely on their clinical skills, but also have to be able to demonstrate skills in care coordination, preventive medicine, team-based care, and continuous quality improvement.
Care Coordination and Transition Management
Underlying all of these principles is the idea of care coordination. According to AHA, coordinating care to meet the specific needs of a patient in both their medical care and other needs is the best way to delivery high quality healthcare.
Care coordination varies from health program to facility and even from patient to patient. Whether care coordination is episodic versus longitudinal, in the community versus in a hospital setting, a function of the entire clinical team versus a specific role for a care coordination professional, the broad array of relationships and interactions are focused on patient health and appropriate care coordination and delivery.