Transitions of Care 2022
What Are Organizations Using or Considering to Facilitate Effective Care Transitions?

About Half of Respondents Use Only Their EMR Vendor’s Technology to Support Care Transitions

About half of respondents (51%) use only their EMR vendor’s technology to support TOC and facilitate greater transparency between the care team and patient; the primary use cases are bundling patient information, sending and receiving data, and notifying clinicians of ADT data. However, most respondents don’t leverage their EMR vendor’s technology for additional TOC processes (e.g., prior authorization, patient matching, referral management) because achieving and maintaining automation is complex and resource intensive. In these areas, respondents instead rely on manual workflows. Respondents who work in home health settings are the most likely to leverage their EMR vendor’s technology (either exclusively or in combination with standalone technology), while those in long-term care are most likely to use standalone technology (either exclusively or in combination with their EMR vendor’s technology).

Epic, Cerner, and PointClickCare Are Most Deployed EMR Vendors to Address Transitions of Care

In inpatient settings, Epic and Cerner customer respondents say the biggest benefit of using their vendor’s technology is the way all care settings’ technology is integrated, improving the flow of patient data within the organization. Additionally, these EMR vendors offer solutions to help streamline care transitions between inpatient and post–acute care settings. For example, Epic customers use EpicCare Link so home health agencies can view patient records, and Cerner customers rely on interfaces to simplify data sharing with key vendor partners, like MatrixCare. In long-term care settings, customers of PointClickCare say the solution enables clinicians to easily send and track CCDs. In home health settings, WellSky^†, MatrixCare, and Homecare Homebase respondents appreciate the ability to easily send data and say their respective solution enhances transparency during care transitions.

† WellSky recently acquired CarePort and the Curaspan technology—the latter formerly owned by naviHealth and here called CarePort (Curaspan). However, in this report, WellSky, CarePort, and CarePort (Curaspan) are referenced separately.

Multiple Respondents Use Standalone Technology to Supplement Their EMR Vendor’s TOC Offering

Despite EMR vendors increasingly offering TOC functionality, 49% of respondents choose to use standalone TOC technology, either exclusively or to supplement their EMR vendor’s solution. Many respondents haven’t yet utilized their EMR vendor’s TOC functionality. Some respondents in long-term care (28.5%) and home health (20%) have not adopted their EMR vendor’s TOC technology, for reasons such as additional costs and standalone solutions offering more specialized functionality. 44% of Epic respondents either supplement the vendor’s functionality with a standalone offering or solely use standalone technology. Meanwhile, only one of the nine interviewed Cerner customers reports using a standalone offering to supplement the EMR vendor’s technology; most Cerner customers in the inpatient setting believe the vendor’s offering sufficiently supports care transitions because Cerner’s system has been rolled out to the organizations with whom they share data. (It should be noted that Cerner respondents may not be aware of the standalone technology that is often embedded in Cerner’s platform.)

Standalone Vendors Bamboo Health, CarePort, and Forcura Often Used to Increase Data Transparency between Care Settings 

Care transitions between inpatient and post–acute care settings are often a pain point due to manual processes and organizations using different referral management software. Respondents note several standalone vendors that help circumvent these roadblocks. Bamboo Health and CarePort^† (powered by WellSky) allow home health organizations to view ADT information, transfer data to payer organizations, and learn when a patient checks in at the hospital, and both have been validated by KLAS as being live across multiple care settings. Additionally, respondents say CarePort’s referral management technology integrates payer and post–acute care settings to keep PCPs engaged in care coordination. CarePort (Curaspan)^† and ABOUT (Ensocare) users can track and manage referrals that come to their organization, and CarePort (Curaspan) also offers a care management module. Forcura partners with several post–acute care EMR vendors discussed in this report to support care coordination workflows and documentation management; their tool also digitizes faxes and attaches them to patient records, which customers appreciate. National data-sharing networks (i.e., Carequality, CommonWell) are also intended to facilitate care transitions between inpatient and post–acute care settings. However, very few respondents mention using these networks. Of those who do, some report manually entering data into their system even after it is sent electronically.

† WellSky recently acquired CarePort and the Curaspan technology—the latter formerly owned by naviHealth and here called CarePort (Curaspan). However, in this report, WellSky, CarePort, and CarePort (Curaspan) are referenced separately.

Almost 25% of Respondents Are Considering Investments in Care Transition Technology 

Organizations highly value the ability to coordinate patient care and access patient records, and respondents report these are the top two areas that TOC technology can address. 23% of respondents are considering purchasing a net-new solution to support TOC. Most are looking at EMR vendors, hoping they will address customer needs by sharing data with external partners and increasing transparency via tracking and analytics tools. 8% are considering standalone technology. The remaining 77% feel they don’t have the budget for additional purchases or expensive interfaces.

PointClickCare Most Considered for Refining Transitions-of-Care Processes 

Among the respondents who are considering an EMR solution, the top-mentioned outcome they hope to achieve with a new solution is efficient workflows—e.g., acquiring patient data electronically, integrating it into clinician workflows, and sharing it when patients are discharged. PointClickCare is the most considered vendor, with organizations citing the vendor’s large market share in long-term care and their focus on usability and integration with their Nursing Advantage solution. Epic and MEDITECH also appeal to prospective customers for ease of use and integration. Current customers of all three vendors verify the above consideration factors as actual strengths—PointClickCare customers note the vendor’s willingness to interface with standalone technology, Epic customers report seamless data sharing with other Epic users, and MEDITECH customers appreciate Expanse’s improved user interface. MatrixCare is considered by organizations for TOC technology because the vendor is investing in strengthening the home health solution’s workflows; also, organizations believe the vendor is capable of handling regulatory requirements. Many current customers report satisfaction with integration, though others would like MatrixCare to focus more on this area.

About This Report

This report is a perception study designed to help readers understand how organizations are approaching transitions of care and which vendor technologies they are using or considering to facilitate effective care transitions. To gather these perspectives, KLAS spoke to 95 healthcare leaders across multiple care settings and asked them (1) which vendors they use for transitions of care, (2) how their solutions are being used, (3) what benefits they have seen from using their solutions, and (4) what other vendors they have considered to address their care transition needs. Data was collected between March 2022 and September 2022.

Many additional standalone solutions for transitions of care did not come up in this research. Below is a full list of the standalone solutions KLAS is aware of that are available to the market today: