Transitions of Care
Prototyping and systems design to improve care continuity from the hospital to community providers
Background
Travis County’s healthcare system is fragmented between its many providers who use different procedures and systems to manage a person’s care. This context makes it difficult to smoothly transition patients from acute hospital care to ongoing community care. The Design Institute for Health collaborated with Dell Seton Medical Center (DSMC) and community partners to explore how to improve provider coordination and patient experience during transitions of care. This project was split into two phases: the first, a design sprint focused on improving bidirectional communication between hospital and community providers; the second, mapped the transition experience for patients and providers and identified opportunities across the healthcare system.
Results
Through our work focused on discharge communications, we trained and developed tools for internal medicine residents to write effective discharge summaries. This included a proposed redesign of the discharge summary template which is currently being prototyped and an annual curriculum for incoming residents, first deployed in the summer of 2021. Our prototypes increased residents’ motivation and ability to write effective discharge summaries, as well as trust and empathy between hospital and community providers.
We also created a shared understanding of how transitions happen by mapping the transition of care experience from many perspectives. By convening both DSMC staff and county healthcare leaders around these maps, we identified collective priorities across providers and surfaced lessons learned from COVID-19 on how to better support patients.
MY Role
Led project team including a design researcher, systems designer, interaction designer, information designer, project manager, and two DSMC medical residents
Conducted design research with patients and providers to understand their respective contexts and constraints
Drove design strategy to ensure convergence of research, prototyping, and systems mapping across various workstreams
Facilitated stakeholder collaboration by managing partner relationships and leading workshops with health system leadership and staff
Partners
Dell Seton Medical Center (DSMC), CommUnityCare (CUC), Veteran’s Affairs, Austin Geriatric Specialists, Dell Medical School
Team
Adam Zeiner, Andrew Do, Caroline Garry, Diana Siebenaler, Joseph Joo, Mustafa Abdul-Moheeth, Natalie Privett, Stacey Chang, Taylor Cook
DATES
January to July 2021
Process
DESIGN RESEARCH
We conducted observations and 20 interviews with hospital and community clinicians and staff to understand how the hospital team coordinates and communicates about discharge, how community clinics receive hospital patients and information about them, and the barriers and enablers to bidirectional communication. In Phase 2, we conducted 5 interviews and a survey with former DSMC patients to inform our mapping of their experience and to understand gaps and opportunities for for supporting them making successful transitions.
Prototyping & EVALUATION
Based on our research and input from the Transitions of Care Steering Committee (made up of DSMC and community providers), we prototyped two approaches to help residents write effective discharge summaries:
We conducted a workshop for residents where community providers shared anecdotes of how discharge summaries effect their care and then co-designed with residents the essential components of an effective discharge summary.
We created a practical checklist to reinforce takeaways from the workshop while residents wrote discharge summaries.
To evaluate these prototypes, we developed a theory of change and assessed potential outcomes through interviews, surveys, and discharge summary scoring. Residents were more knowledgable and motivated to write effective discharge summaries after the prototypes, and the workshop built trust and empathy between hospital and community providers.
OPPORTUNITY ANALYSIS
To define our focus for forward work, we used the systems leverage framework to assess the impact of potential opportunity areas on different levers of systems change with our partners. We prioritized mapping the transition service design, as a way to identify opportunities to better support patients. We also decided to build on our learnings from our prototypes to standardize practices on writing effective discharge summaries.
SYSTEM MAPPING
Based on our research, we mapped the transition experience from the perspectives of patients, hospital staff, clinic staff, and intermediaries. The maps identified the responsibilities and breakdowns between different roles, the blockers and enablers each perspective faces, and the workaround they employ. We iteratively refined these maps through both in-person and virtual interviews and workshops with our hospital and community partners. Our hybrid approach to engaging folks allowed for a collaborative and inclusive process.
WORKSHOPS
To build a shared understanding of transitions and identify opportunities to support patients, we convened:
Health system leaders from across Travis County to identify weak points and shared priorities in transitions of care. They aligned on the need to address collective challenges on ownership of transitions, coordination across systems, and disconnected technology.
DSMC residents to understand the perspectives of patients and providers involved in transitions. Residents used Jobs-To-Be-Done to take stock of the various medical, social and emotional, and coordination jobs required for successful transitions, recognizing the immense amount of coordination needed between the many people involved. Then, looking at the transition experience maps, they identified lessons learned from COVID-19 and beyond on how to better support patients and ensure effective communication between providers.
discharge summary TEMPLATE
Building on our prototypes, we developed a curriculum to teach incoming residents how to write effective discharge summaries every year. To make writing effective discharge summaries easy, we also proposed a redesign of the discharge summary template based on outpatient provider needs. This redesign is currently being prototyped within DSMC.