There are certain transition points in medicine that are short in time, but outsized in importance. For instance, the moment of discharge, the moment of intake, the moment the patient arrives home after a hospital stay -- these are all brief periods within the scope of care but all have a big impact on outcomes.

And frequently, these moments of transition are attended by providers on the continuum of care that aren’t doctors and certainly aren’t super-specialists. It’s the aides, the nurses, the pharmacists, and the WOCNs that are there during these crucial moments.

Two recent studies put a spotlight on this truth for us… demonstrating just how important this dynamic is.
As Fierce Healthcare explores, “A nurse is typically the first person a patient interacts with, and he or she can set the tone for the entire visit.”  Because of that frontline position, a nurse can play a critical role in establishing a strong patient-provider, family-organization, relationship and even affecting the chances of a patient embarking on the indicated care plan. Nurses can also become a bridge among care modalities, connecting aspects of care, like behavioral care and physical care. A study they explored found that nurses were the crucial provider in a program that aimed to unify and streamline these two care approaches.

Similarly, Fierce Healthcare looked at an issue at Virginia Commonwealth University, in which pharmacists, a key part of the discharge process, weren’t being communicated with effectively: “Even though they are a key part of the discharge process, they had limited information on which patients were closest to being sent home.”

So Kelley Barry, senior clinical applications analyst at VCU Health, built a new system to indicate whether a pharmacist needs to rush to fill a prescription, whether a prescription is being waited for or delayed, or whether it’s been filled. Of course, “Discharge is a critical time for patients, particularly the elderly, and research shows that a more efficient, coordinated approach can ease the transition from hospital to home.”  VCU’s program lead said that the key step was breaking down the silos between the people involved in discharge.

"If you're not all working toward the same goal, you'll never meet it," Barry said. "If we all join in the conversation in real time, it makes things more efficient. That's what everybody really wants. How do we respect everyone's time and give the most updated information that everyone can act on?" 

In both cases — that of the study of the nurses and that of the pharmacist-oriented program, the solutions used:

• Were simple and inexpensive.
• Involved providers across the continuum of care.
• Prioritized sharing information and bringing more people into the conversation.
• Allowed participants to engage on their schedule, rather than a rigid way.
• Didn't wait for change across the system -- they made improvements within an arena they could impact.

These are inspiring examples of people using care coordination, technology, and team-based healthcare collaboration in innovative ways. Did that innovation involve an expensive or technologically-advanced tool?  No. And that's just what makes these solutions so ingenious.

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