Bridging the Gap: Using Hixny Data to Power 30-Day Transitional Care

Effective transitions of care are critical, high-risk periods where fragmented communication leads to poor outcomes. This presentation highlights the vast range of information available in real time and how that information flows among members of the patient’s care team to evolve from a fragmented, disease-focused discharge to a unified, patient-centered care plan that addresses each patient’s complete needs - clinical, behavioral, and social. HIxny’s Snapshot includes: Real-time alerts to notify care managers immediately when patients are discharged from any hospital across New York State. Advance directives and medical orders for life sustaining treatment (eMOLST) forms, to understand patient goals, lifestyle and preferences. Accurate, real-time information about the hospital stay including medication lists, diagnostic test results. Data on depression, anxiety and cognitive screenings and information from the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) database to understand the patient’s challenges with following post-discharge instructions. Information about non-medical factors that influence health, such as housing transportation and food insecurity that may present barriers to care and the need for community support for the patient. Leveraging technology including hospital alerts and health information exchange ensures information about the whole-patient is available to support safe and efficient transitions of care in accordance with the patient’s preferences – resulting in lower cost of care.