3 Best Practices for Better Transitions of Care

During transitions of care, mistakes can easily lead to your patients slipping through the cracks, conditions declining, and unnecessary hospital readmissions. Working with thousands of SNFs, HHAs, and hospitals, here are three best practices that we’ve learned at Cortex on how to maximize positive outcomes by providing your patients with a smooth transition from one provider to another.

Communicate, Communicate, Communicate

Did you know that up to 15% of patients referred to another provider are never taken under care (NTUC)? When discharging and referring a patient, simply sending the documents and hoping for the best is not adequate. The best way to ensure your patient gets the care they need is to make actual contact with the next provider in line. Consider a referral platform with built-in communication tools, which allow you to more easily coordinate care and track current status in the context of the patient’s record.

"15% of patients referred to another provider are never taken under care."

Build a Preferred Referral Network

The days of sending patients to whoever bakes the best cookies are long gone. The healthcare industry is increasingly driven by data and performance metrics, and your choice of referral partners should be no different. You can dramatically increase your own performance, patient satisfaction, and clinical outcomes by choosing to work only with network partners that consistently perform well. Whether you’re using publicly available data from CMS, or a proprietary source (preferably not self-reported!), pay close attention to the key performance indicators of your partners, such as patient satisfaction scores, hospital readmission rates, NTUC rates, etc.

"The healthcare industry is increasingly driven by data and performance metrics, and your choice of referral partners should be no different."

Check-In Proactively

It is tempting to think the job is done as soon as you’ve discharged and referred a patient elsewhere. But the truth is we all share in the longer-term responsibility of making sure patients are doing well after they’ve received care. It is both meaningful to your patients, as well as the right thing to do, to check in on patients from time to time with a simple phone call. You’ll be amazed not only at the praise you receive from patients for doing so, but also the number of concerns you can catch before they devolve into an emergency. Hospitals, payers, and others will love that you’re doing this, so make sure to keep a record of your calls or outreach!