How technology is improving care transitions

July 16, 2021
Categories: Home health, Hospice, Palliative care
Reading Time: 3 minutes

Patient care transitions have historically been a challenge in every care setting. Due to lack of information and the difficulty of sending information between providers, post-acute care settings—especially home health and hospice—have often struggled to obtain all of the information they need to effectively care for their clients. This transition process is often described as a “black hole” since complete patient information can be difficult to obtain, often leading to clinicians working with limited information, which can be dangerous. Accurate, up-to-date information is crucial for collaborating with their clients and physicians to create appropriate plans of care and positively impact patient outcomes.

Conversely, hospitals and PCPs can struggle to see information from home health and hospice providers, leaving them in the dark about what’s currently going on with their patients.

The post-acute referral: A manual process

Typically, when a referral is made into the home health and hospice setting, sources either fax the information or a request is made for a liaison to physically pick it up. Once the patient data arrives in the home health or hospice office, it’s hand-keyed into the system—a time-consuming process (10 to 15 minutes per patient) that can lead to accuracy issues.

How technology can improve the transition process 

Patient care transitions are typically a manual, labor-intensive process for many organizations, but technology can transform it into a positive experience and enhance patient outcomes. Here are some examples:


The ability to receive referrals via direct secure messaging is a great option for sending patient information like demographics, medications, allergies, etc. This data should auto-populate directly into your EHR and be editable as needed. Clinicians need to be able to see this information at the point of care, so they can sit with the patient and reconcile the data accurately.

Nationwide provider networks

With access to nationwide provider networks, such as CommonWell and Carequality, organizations should be able to query directly through their EHR for patient encounters with facilities or physicians and choose which associated documents to save to the patient record.  This helps bridge the gap for any information that may have been excluded from the original referral. The EHR should also have the ability to contribute to the networks so that a provider or facility can run a query to obtain patient information related to their progress with home health or hospice plans of care.


With this integration, post-acute clinicians can pull medication fill history by date range for immediate, up-to-date information on prescription details and dosages.  This date-filtered approach gives the nurse at the bedside the information to educate the patient on appropriate dosing—helping to prevent patients from taking multiple doses of the same medication from before and after their hospital stay, a common problem that can lead to an adverse event and even rehospitalization.

Outbound direct secure messaging

Outbound direct secure messaging from MatrixCare helps providers and facilities stay in the loop after the patient transfers to home health or hospice. This also gives agencies a way to electronically send referrals to outpatient rehab or alternative living locations, often improving the back-and-forth referral relationship along the care continuum.

Event notifications

This feature provides the ability to send and receive notifications to and from provider networks when a patient changes a care setting. In the past, care transitions were largely unknown, so this technology alerts the whole community of care providers on the provider networks with this information.

As interoperability improves, care transitions will follow

With better communication and easier access to information, providers and clinicians will be able to make better decisions and provide optimal care. As we look to the future and consider how transitions of care will evolve, the growth of interoperability will help lead to positive outcomes for patients and everyone involved with their care.

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Kerri Harpole
Kerri Harpole

Kerri Harpole RN, BSN is the Director of Product Specialist with over 20 years of clinical, management, and business development experience in healthcare. She has served in roles as an RN, Executive Director, Clinical Director, and Care Transitions Coordinator, and Field Nurse within the home health industry. She has also worked as a Care Transitions Coordinator assisting with admissions for hospice. Her experience also includes acute care nursing, implementation, account management, clinical education & training, business development, and medical device sales.

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