In a crowd-sourcing exercise, most participants (58%) agreed that care plans fail to include medical and social factors, fail to coordinate interdisciplinary input (including patient input), do not include processes and milestones, and are not reconciled across time and setting.
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More than 50% said essential care providers often have no input into the transition plan, including the primary care physician, the public health department, family, home health agencies, and pharmaceutical companies.
Among the most promising existing IT solutions, according to the group:
Lasting and significant change will require large-scale, systemic change, said George Bo-Linn, MD, chief program officer of the San Francisco Bay Area Program with the Gordon and Betty Moore Foundation. "By expanding the smart use of health information technology during transitions, we are paving the way for smarter, lower-cost health care and new levels of sustainable healthcare quality."