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maybe that would have solved it. But this lack of communication
is what causes problems.”
A longtime colleague of Dr. Rowe’s, Mary Henry, MD, of Norton
CMA-Geriatrics and Norton House Calls, has higher hopes for the
future. “I think the process of transitions of care is slowly improving,”
she said, cautiously optimistic. “Patients are much more complex
and much sicker than 10 years ago when they leave the acute care
hospital. Even though written communication is important, nothing
compares to MD to MD or MD to triage nurse verbal communication. However, I think the changes in the new forms give a much
clearer picture of the patient’s situation, both medical and social.”
She continued, “I think a major difference now, as compared to
20 or so years ago, is that hospitalists and nursing home specialists
handle so many of these transitions. We need to communicate better
with primary care doctors.”
“My favorite example of a dysfunctional transfer happened years
ago,” said Dr. Henry, who also worked with the GLMS transitions
of care work group. “A patient had been in one of the local hospitals with a hip fracture, developed a stage II wound on the coccyx
and then came to the nursing home for rehab. The wound actually
worsened a bit before it improved. The patient required readmission
to the hospital shortly after the first transition of care from hospital
to nursing home. The ER nurses did not like the appearance of the
wound and called APS to report it as poor care. Thus, they were
essentially reporting themselves to APS. Had there been better
communication, they might have realized the wound had developed
in the hospital but was being appropriately treated at the nursing
home and APS would not have been involved.”
When Dr. Williams began working in surgery in the 1980s, the
process of physician to physician communication was very different
and certainly more personal. “We’d sit down at the beginning of every
day before we started surgery,” he said. “We’d get there at 7:00 or
7:30 a.m., go down the list of our patients and talk about every one.
It was face to face. You got a little bit of quality assurance. You got a
more in-depth idea of what was happening with each patient. Then,
at the end of the day, we sat down again and made sure everything
was done and followed up on. This way, almost nothing got missed.
But we didn’t have the volume of patients we have to see now and
now some problems are more complex.”
Damian Alagia, MD, MBA, is the Chief Physician Executive for
KentuckyOne Health and colleague of Dr. Williams. In his position,
Dr. Alagia’s primary responsibility is to oversee quality and safety
throughout KentuckyOne and engage physicians by providing them
with necessary resources.
“Transitions of care issues all come down to communication and
expectation,” he said. “In order to provide the most efficient patient
handoffs, you need to understand who the patient is and convey
that information to a large number of people and key decision makers in a timely, efficient manner. You also have to make sure that
information is received. Otherwise, it’s just one-sided.”
Dr. Alagia said a large portion of the problem has occurred due
to the rapid advancements in electronic health records. A much
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more personal physician/patient relationship was supplanted by
technology. “Everything was checked, but the patient was left at
the bedside. Now you see a health care checklist often framing the
patient’s level of illness, and then you’re validating that at the bedside
so everyone is working in a more coordinated way.”
While changes in transitions of care are being made for the better, Dr. Alagia said the process still has a long way to go. “I always
want things done yesterday, but making patient transitions and
patient care better is really more of a change in thinking than it is
a change in technology.”
Dr. Alagia said he’s been considering putting someone such as a
chief medical officer or assistant expressly in charge of transitions
of care. That person is responsible for overseeing transfers, making
sure they’re seamless and no balls are dropped and the patients have
a great experience.
“You can get people thinking, but it’s like an exam. Sometimes
you do it, and then you forget what you learn. To get this to stick
requires repetition and a change in culture, and those can be more
challenging than anything else,” said Dr. Alagia. “But I’m optimistic
because we have great physician and nursing leaders in our system.”
Still, there are multiple hurdles to pass, not the least of which is
making the streamlining of transitions of care a top priority even
over things such as admission rates, blood utilization, etc. “We need
to make sure these things are embedded in the cultural fabric of the
institution, because if you try to do too many things at one time,
then nothing sticks as well.”
Velinda Block, DNP, RN, NEA-BC, KentuckyOne Health Chief
Nursing Officer and Senior Vice President, works with Dr. Alagia
to drive clinical strategy throughout KentuckyOne. Together, they
are charged with insuring that KentuckyOne has positive patient
outcomes and consistent care. Ms. Block’s job largely consists of
communication. She works with chief nursing officers in facilities
throughout Kentucky to try to make the best, most up-to-date care
consistent across all of her facilities. “The beauty of being in a large
system is bringing people together, meeting with people on a regular
basis and sharing those best practices,” she said. “If for example we
found a way to drive down infection rates in Lexington, than let’s talk
about what was done, how it was done and how it can be replicated.”
In addition to physicians looking for more effective means of
transitioning,