SFHN Cross-Continuum Care Transitions: Dashboard, Discharge Database Streamline Patient Handoffs

Thursday, March 12th, 2015
This post was written by Patricia Donovan

Dr. Michelle Schneidermann and the SFHN Care Transitions task force mine administrative data to streamline patient handoffs.

As a physician, Dr. Michelle Schneidermann is accustomed to the clinical data driving daily decision-making: blood tests, x-rays, blood pressure readings.

But as part of a multidisciplinary task force charged with improving care transitions within the San Francisco Health Network (SFHN), Dr. Schneidermann faced a “black box” of administrative data buried in more than 60 siloed databases across the health network.

During Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, Dr. Schneidermann described how SFHN’s development of a dashboard, a database and uniform practices has helped to streamline care transitions across its care continuum.

Early on, a data analyst pulled together the siloed databases into a cohesive dashboard providing numerous insights on readmission rates, vulnerable populations, and pain points within SFHN—learnings that sparked action plans, pilots and partnerships designed to standardize patient handoffs and post-discharge follow-up.

One key strategy of the task force, which Dr. Schneidermann described as a “multidisciplinary village,” was a decision to engage primary care leadership.

“Most of our patients leaving San Francisco General go home from the hospital,” said Dr. Schneidermann. “Their post-acute care is in their primary care home. For that reason, we decided that engaging primary care leadership would be a key strategy for our improvement work.”

The population served by the network is largely uninsured or underinsured, and at high risk for readmissions, she added.

After piloting post-discharge outreach tactics at three separate primary care clinics, the task force identified a fundamental knowledge gap: the clinics had a hard time identifying which patients had been discharged and when.

Enter a hospital discharge database retrofitted into the electronic medical record (EMR) that populates each night from hospital censuses— a tool that has improved clinic staff workflow.

Not all interventions are technology-driven. The task force has also engaged primary care physician champions, and placed pharmacists in clinics where possible.

Having concluded its second year, much work still remains. Readmission rates have not dropped as low as the task force would like; the impact of behavioral health readmissions on overall rates is now being studied. The task force also hopes to bring the patient’s voice to bear.

“In theory, it would be most helpful to have representation from patients with chronic illnesses requiring significant self-management skills, who are also challenged by psycho-social barriers to care,” Dr. Schneidermann concluded.

Listen to Dr. Schneidermann outline the responsibilities of the three task force sub-groups: inpatient, outpatient and pharmacy.

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