There has certainly been a trend in medicine towards centralization, silo-ization and consolidation.

I think that you can see it best in the reverence many patients have for major hospital systems. When someone has a challenging diagnosis, the first thought is always to find the biggest, most well-known hospital system, and pursue “the best” care, there.

But a systematic study I read last week upended all of that, showing that mergers and consolidations may actually increase costs and prices.

I believe there is also a somewhat superstitious sense within the medical community that small, community-based approaches may be “nice” but that they are inherently less efficient and more costly than consolidated, centralized approaches. When I was in private practice, there was always an underlying understanding that it may be quaint to practice in a small, community-based medical group but that it would be more efficient -- in cost savings to us and price savings to the patient -- to practice within a hospital system instead. 

This never sat well with me, even though I could hope for the myriad efficiencies that streamlined communication and thoughtful care were creating. So I was curious to read this study that looked at the effect of hospital mergers 2010-2013 in 25 metropolitan areas. 

Overall, the study showed that prices in most areas increased between 11% and 54% for years after the merger, in most areas. And, “prices rise even more steeply when these large hospital systems buy doctors’ groups, according to Richard Scheffler, director of the Petris Center. It's hard to tell from the data whether the price increases come from increased costs or from decreased competition (meaning higher prices due to market distortions.) 

Consolidations don't seem to be slowing. And the biggest of the bunch -- for instance Dignity Health and Catholic Health Initiatives, have 139 hospitals in 28 states and are truly staggering in size. As these consolidations happen, prices rise consistently and often, hospital access goes down as patients are forced to travel farther for care.

Truth be told, I don't know enough about the vagaries of incentives or regulations at the macroeconomic level to suggest a solution. But I do think that the phenomena themselves, as described by the study, suggest the value of diversity in our healthcare system. 

Bigger and more centralized is not always better. The way to achieve efficiency and scale is by more types of providers working more closely together -- across lines of specialty, training, geography, and time -- not by mergers. Yes, a diverse coalition of the small -- rather than a forcing of everyone to become big -- requires more tools and sophistication. But I believe that healthcare collaboration is a better route to efficiency and access than every hospital becoming a mega-hospital. 

To learn more about alternatives to consolidation and mergers, download our Quick Guide to telemedicine: 

It's easy to feel like better handoffs and better communication is a "nice to have" or something that we can resolve, as providers, once we have more time. 

We hear about tools to facilitate medical collaboration and we tend to think, "Well, that's so nice. Maybe once I get the big stuff resolved, I can move on to refining things like that."

We know from our work with iClickCare that medical collaboration IS one of the big things in medicine, very much not a "nice to have." But a recent study that looked at handoffs and communication from hospitals to Skilled Nursing Facilities (SNFs) really brought this point into relief and made the negative consequences of poor communication at discharge incredibly clear. 

More than 5 million people transition from hospitals to Skilled Nursing Facilities (SNFs) annually. The investigators in this study did detailed focus groups and interviews with SNF nurses, looking at that transition and the communication and medical collaboration that happens -- or doesn't -- and what the consequences are.

It's interesting and smart that the study looks at nurses rather than physicians. There is a lot of investigation around handoffs to physicians, but the handoffs to nurses have been looked at less. And nurses in SNFs play the primary role in managing handoffs and discharge to SNFs. 

The conclusions in this study are fascinating and are also crucial to both SNFs and to hospitals. As the study reports, “Discharge to a SNF is one of the strongest predictors of experiencing rehospitalization within 30 days.” And the study concludes, "High-quality, complete discharge communication is vital to safe and effective hospital-SNF transitions.”

The investigators interviewed 27 registered nurses from 5 SNFs in Wisconsin. Facilities ranged from urban to rural, and from 42 to 184 beds. They spoke with the nurses about handoffs and discharge. And poor quality discharge communication was the major barrier they identified to safe and effective transitions. “From the perspective of SNF nurses, difficult hospital-to-SNF transitions were the norm, and when asked to recall the details of a good transition, none were able to do so.”

The issues they identified are crucial, both because they are significant, specific, and also because they can be easily addressed by existing telemedicine medical collaboration technology. 

Discharge communication issues in Skilled Nursing Facilities (SNFs) that nurses identified:

• The information they get from the hospital is inadequate, incomplete, and incorrect.
  SNFs need specific, up-to-date information about the patient including “remarkable hospital events; written orders for medications, treatments, activity level, and diet; recent and pending laboratory test results; accurate descriptions of functional and cognitive status; and pertinent social information, such as preferences and unique needs.”  Both the medical and the social plan of care are important. And they found that when they do intake for a patient, much of this information was missing or conflicting.
• Information is coming from multiple sources, but they are often conflicting.
  Transition information came from three sources -- the patient, the family, and the hospital -- and they had to synthesize it and try to fill in the gaps.
• There is no good means of communication or collaboration with hospital staff.
  It is very difficult to contact hospital staff for any clarifications or to reconcile discrepancies. They don’t have contact information and don’t have the right contacts.
• Inadequate information, presented in challenging ways, creates care delays.
  At a patient’s arrival, SNF nurses often receive “reams” of paper, sometimes exceeding 80 pages, most of which isn’t relevant to the plan of care. They spend hours navigating records and often have to go through the entire printed electronic health record to figure out an accurate history. Discrepancies are often not reconciled for several days. Nurses often end up going in circles to try to get information, where no one provider actually has all of the information. SNF nurses said, “The primary states… ‘I didn’t know what happened at the hospital so I can’t give you any orders…You need to call the hospitalist or whoever worked with them.’”
• Getting information from families is usually not a good solution.
  Nurses sometimes try to get additional information by asking individuals and families but there are three problems with this approach:
• They often aren’t informed enough to offer quality information.
• Asking them creates a poor impression of the SNF.
• Medical orders are legally binding so they need to reconcile what they hear with the orders.

With all of these issues, nurses say they are mostly “working blindly" when they receive a patient. And that's not a matter of inconvenience, it can be a matter of life and death. The study reports, “Missing or incomplete information resulted in care delays, which threatened individual safety and produced individual and family dissatisfaction with the transition process... In one example, an individual who had bilateral lower extremity casts was left in bed for 1 week as the SNF nurses repeatedly requested and waited for clarification of physical activity orders and cast care.”

Also, these communication issues can be a major problem for the reputation and trust in SNFs. “Care delays and implementation of an inappropriate plan of care resulting from inaccurate information produced significant individual and family dissatisfaction and made the SNF facility appear unorganized and ill equipped to care for individuals. This experience produced substantial stress and frustration in SNF nurses.”

Our frustration in hearing about this kind of problem is huge. Not because it's a concerning public health problem, both in terms of medical provider burnout, and in terms of providing adequate care for our patients... but because we have the tools to fix this. 

Ultimately, this blog is not about advocating for iClickCare as a tool. And if you can find a better telemedicine tool for medical collaboration and communication around handoffs, you should use it. But we see several key reasons why iClickCare a crucial tool to support communication with SNFs, essentially fixing all of the above problems in a simple and cost-effective way: 

• Multiple voices, in one place. 
  One of the primary issues that SNFs face is that there is information coming from multiple providers and sources in multiple institutions and they can conflict with each other. iClickCare keeps all of these voices in one simple patient record, which means that when there are conflicts, they can be resolved quickly. Also, it allows communication across the continuum of care, so that whether it is a physician, generalist, hospitalist, aide, or nurse, all of their experiences about the patient's status can be integrated and incorporated. This also helps ensure that both the medical and social and personal context for care plans can be communicated -- rather than the picture being stripped down to just "orders", leaving nurses to guess about things like cognitive condition or personal context.
• Simple communication for busy people. 
  Nurses in SNFs identified contacting hospital staff -- and even knowing who to contact as a key barrier to effective discharge with adequate communication. With iClickCare, you don't need to play phone tag, hunting down the provider who last saw your patient. You request a consult and the other providers can answer your questions quickly, but on a schedule that works for them, and without needing to track down contact information. Further, words, pictures, video clips, and PDFs can be used to clarify issues and make sure that everyone is on the same page. 
• More efficient development of care plans. 
  It's downright dangerous to delay care for hours or even days because there is inadequate information at discharge and it takes days to resolve the issues. With iClickCare, the process is more efficient because you're using the power of telemedicine to navigate care, asking key questions of the right people.

If you're experiencing communication or discharge challenges in a Skilled Nursing Facility, we urge you to use a telemedicine tool to resolve them. You can try iClickCare for free, for 14 days. Download it here: