A patient moves from one care setting to another, but does he or she know what to do next?
Transitions of care — also called patient handoffs — are an essential part of population health management, one that community health centers (CHCs) managed long before population health became a buzzword.
CHCs have extensive experience meeting the requirements of value-based programs while serving disadvantaged communities. By managing transitions of care, they help patients obtain the best treatment possible.
How do they do it?
Get connected
Interoperability enables the electronic exchange of data and gives providers the most up-to-date information on their patients. Many CHCs use an interface to exchange information with providers when a patient is hospitalized. How and with whom you connect will depend on where your patients go for care outside your four walls.
Coordinate care
By forming relationships with trusted specialists, you can ensure your patients remain in good hands. CHCs often have teams dedicated to coordinating care for high-risk patients. Team members follow up on next steps, review overall progress, and solicit the patient’s input on their condition and treatment.
Plan for emergencies
If your patient visits the emergency department, schedule follow-up appointments as quickly as possible. Patients who have experienced an acute event often require changes to their care plan. They also may require medication reconciliations to avoid adverse reactions.
Commit to population health
Many CHCs manage transitions of care while serving patients who need special attention due to language, literacy, or income barriers. It isn’t a simple process, but it can be done.
For more about population health management, and to find out if your practice is prepared, check out our quiz.
