How to make care transitions safer for long term care residents

Posted by Susan C. Hull on Sep 3, 2020 3:43:00 PM
Susan C. Hull
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Coronavirus cases and deaths in long-term care (LTC) facilities continue to rise despite the strictest protocols to prevent it from entering facilities and contain it once it enters.

The coronavirus disease 2019 (COVID-19) has devastated nursing homes across the world and in the United States (US). As of September 4, 2020, over 76,000 deaths have occurred in US nursing homes and other LTC facilities, accounting for 41% of all COVID-related fatalities nationwide (with 47 states reporting). Many consider and label nursing homes as “ground-zero” for the spread of the virus.

With the rapid onset and progression of the illness, residents in LTC facilities diagnosed with or suspected of COVID-19, make multiple and frequent care transitions. These include more frequent bed transfers, or movements in and out of the facility, or to other facilities to accommodate isolation requirements or to escalate level of care. Sharing this care transition data with resident’s family caregivers is part of the new CMS regulatory requirement.


LTC administration and clinical leaders face four challenges to assure and protect health, well-being, and safety of residents, during care transitions.

1) Conditions of aging and dementia impact communication outcomes

In the US, for example, more than 2 million Americans reside in LTC facilities. Nearly half (48%) of nursing home residents are living with Alzheimer’s or other dementias. These and other chronic conditions of aging make communication practices and outcomes during care transitions and the pandemic even more challenging.

2) Limited or no participation for families in care transitions due to COVID-19

Vulnerable older adults residing in LTC facilities rely on their family involvement as crucial factors to enable them to reside and stay in a facility setting. Due to the infectious nature of COVID-19, family members have limited or no participation in resident transitions in and out of emergency, hospital care, or rehabilitation facilities. More so, the return for the resident to the LTC facility requires coordination and communication between the hospital discharging team, the nursing home care team, primary care and community specialists. Families are often out of the loop. They may only receive a parallel or second-hand communication about when, how and where the resident can re-enter the LTC facility.

3) Limited EHR adoption and clinical data sharing between LTC and acute care

LTC facilities have been slow to adopt EHRs and have limited clinical data sharing with acute care hospitals’ EHRs during care transitions. A recent study measured US hospitals’ adoption of EHR functions that support care for older adults and electronic health information exchange/communication with patients, caregivers, and long-term care providers. The online national random sample focused on structured documentation of the 4Ms (What Matters, Medication, Mentation, and Mobility) and found:

  • Structured EHR documentation of the 4Ms was fully implemented across all units in less than half (42%) of hospitals.
  • All exchange/communication functions had been implemented across all units in 7.6% of hospitals
  • Less than half of the hospitals had an EHR portal for LTC facilities to access hospital information.
  • Less than half (45 %) in at least 1 unit, sent information electronically to LTC facilities.
  • Less than a third (32%) had training for adults/caregivers on the patient portal.
  • The lack of EHRs and support for LTC facility reporting remain a barrier—to COVID-19 reporting and continuity of care.

4) Communication activities separate from clinical care and condition updates

Family members need meaningful clinical data about the care and condition of the resident, including changes in medications, diet changes and lab results, including COVID-19 testing status and results. Communication approaches unintentionally fragment, rather than tie together, the communication to the resident, family and care team.

The optimum way to solve for these challenges is implement an “always on” patient-centric secure and interoperable communication platform to:

  • Improve care team and family preparation for care transitions in and out of your LTC facilities.
  • Empower residents, families and care teams with real-time care and condition updates to ensure safe care transitions.
  • Provide clinicians to single sign access from their EHR system, to a HIPAA-secure method for communicating with the patients and other healthcare providers on the care team.
  • Loop in providers outside of your facility, with secure chat and access to relevant clinical summary and timeline data.
  • Leverage communication pathways to monitor and collaborate on resident symptom surveillance and follow-up care, after emergency/urgent care visits.
  • Provide a safety net approach for patients, families, and care teams.

In Summary, care transitions can be safer when a resident is moving between care facilities. CareLoop’s interoperable communication platform solves for care transition communication and health data sharing challenges between the acute and LTC facilities. CareLoop provides a safety net approach for residents, families, and care teams, keeping everyone needed in the loop to make resident communication seamless. During a public health emergency (like COVID-19), this brings peace of mind to everyone supporting the resident in the center.

Learn more about how to assure safe care transitions and care coordination for residents and families in LTC facilities. Download a free eBook, How to Streamline Long Term Care Communication During a Pandemic.

long term care communication during a pandemic or infectious disease event

Topics: Care Transitions

Susan C. Hull

Written by Susan C. Hull

Susan is a nurse executive, entrepreneur and informaticist passionate about transforming health and care through co-production. Board certified in nursing informatics and advanced nursing executive, her experience spans diverse roles including designing and managing a new children’s hospital emergency service, nursing and health system executive, healthy community partnership and community health information network (CHIN) executive, chief nursing and health informatics officer, consultant and researcher. Her leadership experience builds on participation in the start of the healthy community, population health and learning health system movements.

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