New exchange technologies promise safer transitions to long-term care facilities

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Nam Nguyen
Nam Nguyen

Long-term care facilities strive to provide each patient personalized care. Comprehensive care plans, honoring patient preferences and tailoring services to patients are critical aspects to achieving the healthcare goals of patients and their care providers.

Unfortunately, in practice, there are many challenges to providing personalized care: fragmented information, poor transitions of care across care facilities, poor communication between patients and their providers, scarce resources and limited staff time.

Consider the following scenario:

Elise is a 55-year-old woman with a history of chronic obstructive pulmonary disease, hypertension and multiple other chronic diseases. She returns to the emergency department for the fourth time in two months for a COPD exacerbation. The attending physician attributes this readmission to a COPD flare triggered by an exposure to allergens. After her condition is stabilized, she is discharged to an assisted living facility. Elise is placed next to an individual with a cat despite her allergy to cat dander. She does not realize that cat dander is a trigger for her respiratory symptoms.

At the assisted living facility, Elise hands her care provider a bag with 15 different medications, and she is unaware that her physician discontinued two of her medications. Elise tells her care provider that she recalls an additional prescription from her physician, but does not have the knowledge to articulate this additional prescription. Her care provider also enrolls Elise in a new home-meal program, unaware that Elise is already enrolled in a home-meal program that is familiar with Elise's nutritional needs. Her care provider does not have access to any information about Elise's social service needs and is unable to coordinate services to meet those needs. Despite multiple attempts, Elise's care provider cannot contact her care team at the hospital to better understand Elise's needs. Without the proper medication, allergen information and follow-up care, Elise will likely return to the ER for a fifth time.

This example is unfortunately not unique; it represents similar experiences and real-life issues for many of the patients we serve.

Technology for easing transitions

A team of clinicians, data scientists, health services researchers and computer scientists at PCCI, a nonprofit research and development corporation in Dallas is building technologies to combat the challenges of fragmented patient records and poor transitions of care. The W. W. Caruth, Jr. Foundation at Communities Foundation of Texas recently awarded a grant of up to $12 million to build the Dallas Information Exchange Portal (IEP), an artificially intelligent social health information exchange between healthcare and social service providers.

How the Dallas IEP will work

The platform will provide secure access to relevant patient information that will enable care providers to reach across sectors to address risk factors such as homelessness, poverty, food assistance, mental health, chronic disease, mobility and aging, particularly for the most vulnerable patients. It's a true breakthrough in the fields of medicine and social service.

Artificial intelligence operates on top of the exchange platform to interpret patient data, predict the risk of adverse events and recommend targeted interventions. The PCCI team aims to leverage the IEP technologies for improved care coordination within and between the healthcare and social services sectors. Skilled nursing facilities are among the many types of organizations that can participate in and benefit from the Dallas IEP.

“My team at PCCI and I believe that the Dallas IEP will connect care providers and empower patients in a way that has never been achieved before,” said Ruben Amarasingham, M.D., president and CEO at PCCI. “Far too often, critical knowledge about patients' clinical and social needs is lost as they move between care centers such as hospitals, clinics, homeless shelters and food-aid organizations. The results can be devastating – early mortality, frequent hospital readmissions, low birth weight and chronic disease complications. With the Dallas IEP, we can help solve this problem.”

Putting patients first

Through the Dallas IEP, patients can receive the custom care they need. With the IEP, for example, Elise's care providers at both the hospital and the assisted living facility could communicate about her medication needs to ensure a safe transition. By sharing relevant resources and patient information, the assisted living facility could have better access to critical patient information.

With the patient's consent, the Dallas IEP enables the appropriate care providers to access relevant clinical information such as prescribed medications, allergies and dietary restrictions as well as relevant social information such as insurance, housing, functional status and transportation needs. This information helps care providers from disparate organizations deliver the safest and highest-quality care, tailored to their patients' needs.

The future of healthcare

The work of PCCI builds on nearly two decades of efforts nationwide to establish and maintain health information exchange systems; it pushes the boundaries of health information technology. The importance of community-oriented information exchange systems cannot be overstated. Anand Shah, Executive Director to the Dallas IEP, says, “Information exists in silos today, and for long-term care facilities to deliver the best care, we need to facilitate the exchange of information so our patients get the care that they deserve.”

Nam Nguyen is the operations officer at Dallas Information Exchange Portal.

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