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Meeting the challenges of communication across care settings

A recent survey asked caregivers what one thing they would like to change to improve patient transitions from an acute care facility to home health or hospice. The number one answer was communication across care settings.

The number two answer was care coordination. But it’s easy to see how these two issues are connected, since effective care coordination can only happen if there is productive, timely communication between caregivers, patients, and family members.

Generally, each caregiving organization uses some type of communication tool, such as a portal or an application. But the challenge lies in the fact that there’s not a communication tool these various caregivers can all use simultaneously. This is especially problematic during patient transitions from one care setting to another.

Here’s an illustration of how fragmented transitions of care can be. If a patient is moving from a facility to home with support of a home health agency, you could have referring clinicians from the facility who need to communicate with the agency’s admissions staff. There is usually a pharmacy making sure all medications are up to date and delivered to the patient’s home on time. There may also be a DME aspect if the patient needs additional equipment such as a pump of some kind or a hospital bed. All of these things must be coordinated to ensure a smooth transition.

Each of these stakeholders uses a communication tool—but none of them has a tool that allows them to communicate simultaneously. A better solution would let members of a care team create or participate in discussion groups related to a specific patient’s care: staff from the facility, from the home health agency, the pharmacy, the DME supplier, even the family. With this kind of tool, when a patient is set for discharge, the entire team would know what DME is needed, when it will be delivered, what medications need to be delivered, and when agency staff need to arrive in the home to check on the patient and meet with family members.

There are several reasons it’s better to coordinate communication and care. One is related to costs. For example, if a patient’s transfer from a facility to home-based care is delayed, that can add several hundred dollars of costs each day the care transition is postponed due to a lack of communication. Or if a patient goes home but doesn’t have the right meds for two days and has a relapse, there are costs associated with rehospitalization. Another cost is related to relationships with referral partners, who often describe a “black hole” when a patient moves from their facility to home care and they lose visibility into the patient’s status. A platform that allows all caregivers visibility into all aspects of a patient’s care could eliminate all of these challenges.

Another reason communication is crucial for your agency’s success is the patient’s caregiver and family members. Home health agencies spend an enormous amount of time communicating with caregivers and families, especially when home health care continues for months, as can happen with hospice care. When communication is easy, clear, and comprehensive, it not only improves the care quality, but can also improve ratings based on client satisfaction.

I’ll share a personal example about this. My dad was in hospice, and I lived 300 miles away. But as the family member who had home health experience, I was the one in contact with the hospice agency on behalf of my mom, who was his caregiver. If I wanted to take my dad on a short weekend trip, I needed to know what kind of coverage the agency had in that area. But because there was no online communication tool, I had to make a phone call and then wait for a call back to get my questions answered—and between their schedule and mine, that might take two or three days.

A better communication tool could include features like app-less communication, alleviating the need for the recipient to download an app. This would allow information to be exchanged more conveniently, documents to be signed more easily, and patient status to be self-reported. For instance, if my mom had needed help because my dad’s catheter was blocked, she could have messaged the agency, and they could have sent her a video or a PDF with instructions to clear it, saving them having to send someone out, and saving the time my parents would have spent waiting to have that resolved.

All these reasons point to the advantages of a communication platform like MatrixCare Link, which allows entire care teams to communicate, coordinate, and work seamlessly to improve care transitions, care quality, and patient and family satisfaction.

Read our eBook to learn how more and more organizations are turning to technology to simplify communication and deliver a more integrated care experience across settings.

Get the eBook: Care across settings: Technology to meet the challenges

Watch a webinar from McKnight’s


Rob Stoltz
Rob Stoltz

Rob Stoltz, Sr Dir, Business Development Home and Hospice. A long time veteran in the home-based healthcare IT industry with deep experience in EMRs, care transitions, patient engagement, predictive analytics and interoperability. Most recently, Rob has been focused on technology partnerships leveraging interoperability to benefit all stakeholders involved with patient care while enhancing provider efficiency through effective workflows.


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