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5 Care Transition Takeaways From COVID-19


The coronavirus pandemic has also revealed valuable lessons to help us navigate these turbulent times.

While the COVID-19 pandemic has created unprecedented challenges for healthcare providers, it has also revealed valuable lessons to help us navigate these turbulent times.

The following are five key take-aways that will enable providers to develop better care transitions for their patients and prepare for what lies ahead:

1. Clear, concise, consistent communication is critical.

Regardless of the state of business or the world around it, sharing information with employees, patients, their families, and others in the care spectrum is essential. While it sounds simple and straightforward, many healthcare providers and operators have learned during the pandemic that it was anything but.

Rising fears and anxiety brought on by the swirling of conflicting and often unclear information made it difficult for organizations to provide assurance and guidance to peers, staff, residents and families.

“Originally, we overwhelmed ourselves and our clients by sending too much information, without first curating it,” said April Catterton, PCS Manager of myPotential at Home. “Now we understand that first establishing a clear message and then sharing it across the entire organization is a number one priority.”

Rather than responding on the fly, healthcare providers benefit from taking a step back, confirming information and sources, and working to deliver sound messages in a timely manner.

“Increase the level of one-on-one and group communication to ensure you’re on the same page, allocate resources appropriately, and make it as seamless as possible for clients and staff to communicate,” said Catterton. “If you’re managing a highly contagious infection, you should be going through the same processes of communication each and every time.”

2. Walk before you run, quickly.

During a crisis, there’s a tendency to attempt to cover all bases at once. Organizations under fire realize that they can move far faster than they normally do, and they often do it without first covering the basics.

This scattered approach doesn’t work.

Erin Devine, Director of Quality and Community Partnership for the University of Maryland Medical System, said that her organization showed that it could be innovative and move at a speed that it had not traditionally been comfortable, yet they learned that faster isn’t always better.

“We learned that there’s no need to overcomplicate it,” she says. “We rushed to put so many things in place when what we really needed to do was to focus on the basics.”

Start at the beginning by ensuring your skilled partners have the assistance they need, assistance as simple as support for infection control and the right amount of PPE.

3. Informed decisions depend on data.

Looking at past data allows organizations to spot trends, predict outcomes, and formulate more effective plans. But, dealing with COVID-19, an unprecedented crisis, meant there was no looking back for guidance.

That doesn’t mean that data isn’t paramount to successful care transitions and patient management.

Providers navigating the pandemic relied on live, real-time data, including COVID-19 positive patients, pending test results, patient risks, EMS calls, ventilator counts, and ICU rates. That data allowed teams to move equipment and support, rather than people, ensuring safer, more comfortable care transitions.

Some, like Dr. Tere Koenig, an internist geriatrician and Executive Vice President and Chief Medical Officer for Medical Mutual, created a dashboard that enabled them to look at who had been admitted with COVID or potential COVID and who needed high acuity care, such as receiving treatment in the ICU. The data helped them understand capacity needs and adjust resources, as well as provide state-required weekly updates on SNF cases.

“Had we had even more data and a way to share it across a continuum, we would have known where there is an open bed and we could have provided even better care transitions,” she says.

4. Knock down silos.

Collaboration has never been more important in healthcare. Providers need open channels and clear processes for connecting and communicating with each other and with their constituents.

Why? Hospitals and skilled nursing facilities can get overwhelmed with volume, rapidly and repeatedly cycling patients from hospital to nursing facilities. Their time is spent on manually entering patient data rather than interacting with patients.

Collaboration within the healthcare system, with other local hospitals and skilled nursing facilities, helps to better address hotspots when they appear, prepare for transitions, and provide more seamless transfers.

“COVID made us think about the importance of the patient experience, and ensuring that team members at skilled nursing facilities have as much time as possible to spend with patients,” said Lori Baker, Director of Ambulatory Care Management and Senior Services/Post-Acute Care, at TriHealth. “Collaboration between hospital systems and post acute care systems is integral to providing safer, more compassionate care transitions.”

5. Every business needs a preparedness plan.

It’s easy to say “we should have been better prepared,” but the more effective response is “now we know how to prepare.” It’s not too late for organizations to develop or strengthen their disaster preparedness plan.

An effective preparedness plan covers staffing, support, and supplies needed to ensure facilities are equipped to be successful and to execute quickly in crisis. Itaccounts for all patients, provides a broad view, and includes key administrators, associations, departments of public health, local and county health services, health plans, med groups, and anyone else who is involved in patient care. It also dictates how these entities work together and align to be effective and efficient.

“Preparedness starts with knowing your patient population and understanding their needs,” said Skelly Wingard, Mid-Atlantic Vice President, Continuum of Care at Kaiser Permanente.

“Chart-level data helps you to identify high-risk patients and the resources they need, and you need an understanding of your partners so you know who has resources to help when you need it,” she said. “The more data you have and the better you understand it, the better equipped you are to react and intervene when tragedy strikes.”


Learning from this pandemic is far more productive than being overwhelmed or sidetracked by what we wish we had known or had done differently. Taking these lessons to heart will enable providers to provide better care for patients, protect their businesses, and prepare for challenges that may lie ahead.

B.J. Boyle is vice president and general manager of PointClickCare’s Post-Acute Insights division. In his role, Boyle is responsible for leading a team that is focused on enabling hospitals, health systems, and their long-term and post-acute care (LTPAC) partners to better communicate, collaborate, and share critical patient data. With more than 10 years’ experience and expertise in population health and analytics, Boyle is best positioned to lead the development and design of PointClickCare’s Integrated Care Coordination and cross-continuum solutions.

Prior to joining PointClickCare, B.J. held the position of Director of Solution Strategy and Development for Cerner Extended Care, and Director of Product Management for Resource Systems. Boyle holds a B.S. in Information Systems from University of Mount Union, MBA from Point Park University, and Executive Certificate in Healthcare Leadership from University of Missouri-Kansas City.

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