Even With Software, Hospitals and SNFs Struggle with Care Coordination

Seamless handoffs between nursing homes and skilled nursing facilities are an integral part of care coordination efforts under new payment models — and, in turn, financial success. But new study determines that even when providers have tools to ease patient handoffs, they find them hard to use to achieve their goals — or decline to use them at all.

Health information exchange (HIE) programs are underused at hospitals and local skilled nursing facilities, partly because of workflow barriers and design limitations, according to research published Monday in The American Journal of Managed Care.

The study used data from an audit log that captured HIE use by three SNFs to obtain hospitalization information for 5,487 patients discharged to the SNFs between June 2014 and March 2017. The study also included 16 interviews at the discharging hospital and at the HIE-enabled SNFs.

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The SNFs used HIE for 46% of patients for whom it was available, and 29% of patients had records accessed within three days of their discharge from the hospital, according to the findings. HIE use was more likely for new SNF patients, compared with returning ones; it was less likely on weekends and for more complex patients, as measured by number of conditions or length of stay.

The usage patterns varied significantly across SNFs in a single community, the authors noted.

“SNF staff received no training and little instruction regarding how the portal could or should be used to complement these other processes, leading to significant variation in how the portal was used, users’ experiences with the portal, and users’ perceptions of utility,” Dori Cross, Jeffrey McCullough, and Julia Adler-Milstein wrote in the study.

In one SNF, the primary users of the portal were billing staff, who used the system to obtain patient information for Medicare and other payer documentation requirements; in another SNF, the portal was used mainly to help with information gathering about a patient before the patient was discharged to the SNF’s care.

In the third SNF for which audit logs existed, use of the portal was driven by nurse managers and the director of nursing to prepare the appropriate resources for patient needs; that SNF tended to access information prior to or immediately after the patient’s physical arrival.

The fact that use was less likely for complex patients, or for managing transitions when they occur outside traditional business hours, is notable, the authors said.

“This suggests that current HIE infrastructure may not be delivering the value necessary to motivate SNF providers to incorporate system use into existing workflows,” they wrote. “Indeed, qualitative inquiry reveals that nursing and social work documentation from the hospital is critical to supporting postacute care delivery but is often unavailable or difficult to access via the portal.”

Without direction from the hospital, portal usage patterns by SNFs varied greatly. This indicates hospitals and SNFs have to work together to develop policies that clearly state the types of information retrieval and use cases, in addition to providing clarity around when the system can be used, the researchers said. SNFs also should reconsider structural limitations and revisit their workflow design, they noted.

“Current patterns of HIE use by SNFs should not be expected to drive significant improvements in care,” they wrote. “Changing this projection requires adopting a sociotechnical perspective on improving care processes. Hospitals need to engage more actively with SNFs to understand information needs in this setting and organizational constraints (ie, staffing structures, workflows) that challenge care continuity.”

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