IT Helps Smooth Transitions of CareLeveraging Documentation and Embedded Workflow Technology to Coordinate Care across a Health System

IT Helps Smooth Transitions of Care

June 10, 2014 | Care transitions often result in additional work for both the patient and the healthcare providers concerned. Penny Frownfelter, director of nursing at a U.S.-based hospital, explains how she and her team leveraged streamlined documentation and embedded workflow technology to improve care coordination when transferring patients.


In some health systems, it’s not uncommon for patients to feel a sense of déjà vu as they transition from one facility to another – mainly because the questions they are asked and the paperwork they fill out often sound and look oddly familiar. Today, perhaps more than ever, providers need to better coordinate their efforts to maintain continuity of care as patients transition from one setting to another. Care coordination efforts driven by uniform processes and systems can enhance the patient experience and result in fewer readmissions and improved clinical outcomes.
As a provider of acute inpatient rehabilitation services and physical, occupational, and speech therapies, the Helen M. Simpson Rehabilitation Hospital and its parent PinnacleHealth have always stressed the importance of care continuity. As evidence of this, clinical team members at the 55-bed inpatient rehab hospital took on the task of redesigning the documentation they use to manage patient care and rehab activities.

Teaming Up for Better Patient Care
Rehab staff had been working from the same documentation as the acute care Community General Osteopathic Hospital (CGOH) within the PinnacleHealth system. The documentation included valuable information about the patient but was not customized to address the key requirements of caring for a rehab patient. Staff realized that adopting highly automated documentation processes would not only support improved care delivery in the rehab setting, but also ensure that care is coordinated and efficient as patients move across the health system.
The rehab hospital assembled a multi-disciplinary team that included nursing, physicians, nutrition, case management, and IT to redesign the rehab documentation within the Siemens Soarian® healthcare information management system. “While it was important that the documentation be customized to meet the unique requirements of rehab staff and patients, we also wanted to leverage the workflow engine capabilities within Soarian to increase staff efficiency and enhance patient care throughout the health system,” says Penny Frownfelter, MSN, RN, director of nursing at CGOH.

Coordinating Patient Care at Every Stage of a Patient’s Stay
The team at the rehab hospital implemented the documentation changes in steps over the course of two years, beginning with post-acute care before moving on to acute rehab and the various therapies. As a result, the documentation process has improved at every stage of a patient’s experience, including:

  • Post-acute care assessment
  • Rehab admission
  • Functional Independence Measure (FIM) tracking
  • Therapy
  • Discharge


Click on the boxes below to read more about these stages.

Nurse coordinators conduct a patient’s pre-assessment several days before a transfer to the rehab hospital. They review clinical information regarding the patient’s hospitalization, prior level of functioning, and goals at discharge. When they document their findings in the Soarian system’s electronic health record, a consult request is initiated to obtain physician approval. The system’s embedded workflow engine prompts the physician to access the assessment, where he or she can add relevant notes and approve the patient for rehab. The Soarian system then initiates insurance and discharge activities to complete the patient’s transfer to the rehab hospital.

On a patient’s admission to the rehab hospital, nurses review the acute care documentation in the Soarian system before conducting an initial evaluation of physical capabilities. “It’s here that nurses will document goals in a patient’s plan of care and begin developing a therapy plan,” says Cynthia Mastrine, BSN, RN-BC, nurse manager at the rehab hospital. “Soarian leverages this information to populate physical therapy flow sheets that the nurses and therapists will then use to guide their sessions with patients.”

According to physical therapist Tara Krammes, DPT, having all the relevant information available in the Soarian system and being able to navigate through it quickly have improved coordination-of-care efforts as patients transition to the rehab setting. “Data flows automatically from the acute-care hospital, so we have everything we need in the rehab hospital to plan and coordinate care throughout a patient’s stay with us,” she says.

As the primary method for both tracking how much assistance a patient requires for specific tasks and acquiring reimbursements for therapy provided, accurate FIMTM scores are incredibly important to the rehab hospital. The FIM (Guide for the Uniform Data Set for Medical Rehabilitation, 1996) is an 18-item ordinal scale, used with all diagnoses within a rehabilitation population, and is viewed as most useful for assessing progress during inpatient rehabilitation. Members of the care team assess the patient’s physical and cognitive capabilities on the day of admission, during therapy sessions, and at discharge and document their findings in the Soarian system, which calculates the FIM score based on the data and shows its values throughout the patient’s stay.

“Because FIM documentation is automated and captured during the normal course of care delivery, it is more complete, which helps us to comply with regulatory requirements and more accurately track reimbursements,” says Mastrine. “In addition, being able to show consistent progress in FIM scores enables us to more easily get extra therapy time approved for patients who need it.”

Therapists use a “Charge” tab within the Soarian system to document how long a therapy session runs, which is important for billing and compliance purposes. The system automatically breaks therapy sessions into units in accordance with the Medicare 8 Minute Rule, which dictates that in order to bill for a treatment unit, a therapist must have spent at least eight minutes of each unit providing direct service to a patient.

Medicare also requires that 180 minutes of therapy be provided to each patient per day (or a total of 15 hours per week). The documentation and workflow capabilities and automated calculation of time spent for therapy within the Soarian system enable staff to ensure not only that they are meeting these requirements, but also providing the care and therapy necessary to help the patient achieve the goals identified in the plan of care.

Finally, when a patient is ready to be discharged, rehab staff generate a summary report in the Soarian system that automatically pulls in FIM and therapy data and offers the opportunity to update the patient’s functional status and address the goals stated in the plan of care.

As with the previously discussed stages, the ability to capture the patient’s complete experience on a single screen simplifies and streamlines the entire process, enabling staff and patients to quickly see how productive their therapy experience was, while also ensuring all the data required for billing and reimbursements has been collected.

Patient documentation capabilities help improve care coordination.
Patient documentation capabilities help improve care coordination.

Enhancing Compliance, Increasing Reimbursements, and Improving Patient Care
Since bringing the rehab documentation process online in the Soarian system and leveraging its embedded workflow engine, the rehab hospital and PinnacleHealth as a whole have experienced a number of significant benefits.

According to Cynthia Mastrine, BSN, RN-BC, nurse manager, being able to alert clinicians to the need to complete documentation via workflow technology has resulted in improved documentation compliance. “Prior to our redesign in Soarian, initial nursing assessments were completed 72 percent of the time,” she says. “Today, our compliance level is 100 percent for those assessments.”

Melissa Gillis, OTR/L MPA, administrative director at the rehab hospital, has also seen impressive improvements in the health system’s documentation of therapy activities. “Using the Clinical Summary within the Soarian system, our clinicians can ensure the required amount of therapy is provided and complete the necessary follow-up when it is not,” she says. “We have seen a 52 percent increase in our ability to meet defined therapy requirements since implementing the new process – and that has had a direct impact on our reimbursements.”


The plan of care keeps the staff up to date.
The plan of care keeps the staff up to date.

Benefits for Patients and Staff Alike With Patient Documentation Software
The new documentation process – and the ability for all care team members to review complete electronic documentation as part of the weekly team meetings – has allowed for all disciplines to come together to discuss each patient’s plan of care and make any necessary updates or modifications.

“Since we’re all looking at the same information within the Clinical Summary, we’re better able to focus on a collaborative approach to care and treatment of patients,” says Maggie Cruse-Horan, BSN, RN, CRRN, nurse manager. “The physicians in particular really like it because the conferences are faster and more productive, enabling them to use the time efficiently and get back to caring for patients.”

Lastly, with all care team members working from the same data – which is continuously being updated and refreshed as clinicians complete documentation activities throughout the day – the continuity of care provided to patients has improved dramatically as they move into, within, and out of the health system.

“The automated documentation and workflow technology within the Soarian system have been effective tools in helping us enhance collaborative efforts and facilitate smoother transitions between care settings,” says Cruse-Horan. “We’re following care-coordination best practices that create a more positive experience for every patient within our health system.”