bedridden patient, family member and doctor in hospital room
(Credit: Luis Alvarez / Getty Images)

In an attempt to reduce rehospitalizations, researchers have developed a new app that allows hospitals to speak the same language as the nursing homes receiving their newly discharged patients.

The info-sharing app aims to improve the exchange of patient information and better inform the care provided to nursing home patients. It bridges the gap between medical records systems that use different data storage technologies and offers patient information in a format influenced by nursing home workers themselves.

The development stems from a study that started with a team of experienced nursing home nurses identifying key data points and helping shape the way the tool works and its visual format. The process was detailed in JAMDA, the Journal of Post-Acute and Long-Term Care Medicine.

“The reason that people go to a nursing home after being hospitalized is due to their needs for additional support for medical complexity. Receiving information that is inaccurate or delayed ties the hands of the clinical providers in the nursing home, making it more difficult to provide safe and appropriate care at the time of transition,” co-developer and study author Kathleen Unroe told McKnight’s Long-Term Care News on Friday. “Medications for pain or other medical conditions could be delayed due to a lack of up-to-date information.”

Some conditions, especially behavioral health needs, also may be missed by receiving facilities, and those facilities may be unequipped to treat such needs.

“Not only can this place the patient’s health at risk, it can also put the health and safety of other residents (in the patient’s home or in a SNF), as well as provider staff, at risk,” Centers for Medicare & Medicaid Services Director David Wright wrote in a memo to hospitals earlier this year. “These situations can cause avoidable readmissions, complications, and other adverse events.”

Robust info sharing helps staff

Preventing unnecessary readmissions is one of Unroe’s main areas of focus as a research scientist for the Regenstrief Institute at Indiana University.  She said she has been bewildered by the lack of consistency or movement toward interoperability between healthcare settings.

“This is an issue we have had the technology to solve for a long time, and I and other clinicians are frustrated that the situation varies so much by facility and by discharging hospital,” she said. “I appreciate that CMS is pushing hospitals to take responsibility for transmitting appropriate and timely information to nursing homes to support care transfers.”

The info-sharing app development project focused on how critical information optimally should be presented and integrated into nursing home workflows. 

“A nursing home admission nurse or admitting physician should not have to sift through a pile of paper or dig through lengthy electronic health records to capture basic pieces of data that we need to know on each admission,” Unroe said.

The app provides “robust” information quickly to support what the research team called a seamless transition of care across settings, regardless of which electronic medical record systems the two facilities use. It addresses residents’ medical needs as well as what supports they might need for activities of daily living, explained co-author Joshua R Vest, PhD, of the Department of Health Policy and Management at Indiana University. 

And the benefits won’t necessarily be limited to patients, Unroe added.

“Costs of staff training are reduced if the time is put into thoughtful, user-centered design, such as the results presented in this study,” she said. “Increasing sophistication of medical record systems and a greater push for interoperability mean it is possible to get widespread solutions in nursing homes into use.”

Unroe now plans to advance the prototype into a fully scaled tool for broad use on computers and handheld devices. The researchers plan to test it in real time with actual transfers to confirm that it will support nursing home nurses “to efficiently and safely admit patients as well as to ensure that there is no disruption in the clinical care plan created by the hospital due to transition to a nursing home,” Regenstrief said in a press release.