Transition of Care

Making informed decisions about transition of care for hospital patients is critical for both patient clinical outcomes and hospitals’ exposure to 30-day readmission penalties from CMS.

How can data be effectively displayed to improve consequences in the transition of care decision-making process?

At HealthDataViz, we’ve seen solid evidence that referrals to home health agencies (HHA) services reduce the risk of 30-day readmission to the hospital. At the same time, the data illustrates performance variations between and among HHAs, demonstrating that the quality of services provided is not consistent.

It is crucial to collect and display data in ways that help identify missed opportunities in the discharge process, and focus on specific metrics that detect at-risk patients. Another important goal is to easily and clearly compare HHA performance in current and future referrals.

HDV has created three interactive dashboards to display, highlight, and clarify data for this prototype. The first board filters for an individual hospital and a desired date. The top section displays summary metrics that drill down by hospital service line. The map pinpoints the zip code locations of HHAs with referrals, while a bar graph quantifies referrals per HHA. Each Provider Name is a hyperlink to the Home Health Agency Comparison dashboard.

On the second dashboard, “At Risk by DRG,” is a summary narrative capturing statistics for missed opportunities; a visual trend line highlights these figures. Additionally, the data displays categories and drills down to a specific DRG level. To the right is a payer heat map that uses color hue to identify those at highest risk.

“Home Health Agency Comparison,” the third dashboard, shows—with an easy-to-use side-by-side comparison tool—how HHAs perform on publicly reported quality metrics.

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