Patient Safety Across the Continuum of Care

The problem of information transfer between healthcare sectors and across the continuum of care was examined using a mixed methods approach. These methods include qualitative interviews, retrospective case reviews and an informatic gap analysis. Findings and conclusions are reported for each study. Qualitative interviews were conducted with 16 healthcare representatives from 4 disciplines (medicine, pharmacy, nursing, and social work) and 3 healthcare sectors (hospital, skilled nursing care and community care). Three key themes from a Joint Cognitive Systems theoretical model were used to examine qualitative findings. Agreement on cross-sector care goals is neither defined nor made explicit and in some instances working at cross purposes. Care goals and information paradigms change as patients move from hospitalbased crisis stabilization, diagnosis and treatment to a postdischarge care to home or skilled nursing recovery, function restoration, or end of life support. Control of the transfer process is variable across institutions with little feedback and feed-forward. Lack of knowledge, competency and information tracking threatens sector interdependencies with suspicion and distrust. Sixty-three patients discharged between 2006 and 2008 from hospitals to skilled nursing facilities were randomly selected and reviewed. Most notably missing are discharge summaries (30%), nursing assessments or notes (17%), and social work documents (25%). Advanced directives or living wills necessary for end of life support were present in only 6% of the cases. The presence of information on activities of daily living (ADLs), other disabling conditions, and nutrition was associated with positive outcomes at the 0.001, 0.04 and 0.08levels. Consistent geriatric information transfer across the continuum is needed for relevant care management. An interoperability gap analysis conducted on the LINC (Linking Information Necessary for Care) transfer form determined its interoperability to be the semantic level 0. Detailed Clinical Models representing care management processes are challenged by the lack of consensus in terminology standards across sectors. Construction of information transfer solutions compliant with the Centers of Medicare and Medicaid Services (CMS) Stage 2 meaningful use criteria must address syntactic and semantic standards, map sector terminologies within care management processes, and account for the lack of standard terminologies in allied health domains.