Finding a new path toward patient-centered care

by Tiffany McCauley, MSN, RN

“Fragmented care”

In the big picture, it’s a phrase associated with mergers, acquisitions, and the disconnected technology that often results from consolidation.

But zoom in—past the boardroom where mergers and acquisitions are planned—all the way to the bedside where a patient who has been managing his heart failure for 3 years has now been admitted for an acute exacerbation.

What fragmented care looks like up close is a frustrated nurse, hunting through a chart and struggling to understand how this patient has been managing his condition at home and the details of the care plan that was established in the clinic.

These siloed scenarios can create gaps that risk patient safety. The risks include failure to communicate, error of omission, and duplicate tests and procedures, which all lead to a poor patient experience and potentially negative outcomes. Gaps also create care team dissatisfaction, due to inefficient processes, duplicate documentation, poor team communication.

Today, care teams strive to provide the highest quality care and work in highly complex environments, caring for sicker and more complicated patients.

In an era where seasoned nurses are beginning to retire, patients have more complex diagnoses, and less experienced nurses are often at the frontline of care. It’s essential that health systems support these nurses in providing the highest quality care by providing evidence-based tools that are consistent and shared across the continuum. These tools should also offer efficient access to the patient story, building upon the patient’s care plan and promoting successful management of health.

Jeopardizing patient trust

The shortcomings related to fragmented care directly impact everyone involved—particularly patients, who can lose confidence in their care and get confused about what they need to do to manage their health. These patients are often less engaged and lack of accountability, resulting in unnecessary visits and readmissions.

Think about an organization that has multiple vendors contracted to provide patient education. Each one is likely to use different content and their own care plans and documentation, which leads to inconsistency and its attendant risks.

Now, imagine our heart-failure patient in this scenario. His journey is likely to stretch across multiple settings—from ambulatory to acute care. If his care isn’t  effectively coordinated between providers and the entire care team, the patient experience will be compromised. For example, he could hear conflicting information, undergo duplicate test and procedures, experience omissions of care, and end up being readmitted.

Reshaping the patient journey

To solve the puzzle of fragmented care, organizations will have to soberly assess their culture and ask tough questions. Do clinicians have the tools they need—and do these tools facilitate communication or create silos? Are certain policies and procedures actually disrupting coordination?

Efficiency, effectiveness, and safety all hinge on synchronizing the extended members of the care team as patients move from one care setting to the next.

Let’s return to our heart patient for a moment—how would he rate his experience if his care team was synchronized? He’d likely report far less frustration and anxiety, sensing that each new person he met had been updated and was aware of the big picture. He’d also have a stronger sense that his care was thorough and complete because his team was connected, even as he leaves the hospital to further his recovery at home.

The benefits of unifying care across the continuum

Healthcare systems that can blend comprehensive care planning, patient education, and other facets of the care can dramatically reduce clinician frustration and burnout. This approach can also reduce errors, unnecessary tests, and costly variations in care and re-admissions. And, most importantly, care teams will provide a unified standard of care throughout the entire patient journey to improve outcomes.

Find out how you can empower your clinicians with the tools and information they need to deliver safe, coordinated care throughout the entire patient journey.

And be sure to read our blog, Seeing a new solution to the nursing shortage to learn more about empowering nurses with confidence and competence.

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