Reducing Costs Through Better Care Transition Management

By Greg Bengel, contributing writer

A recent webinar shows providers how to better improve patient outcomes while reducing costs and readmissions rates through data management, integrated communications, and analytics

In the face of Medicare fraud investigations, Meaningful Use incentives, and a shifting focus from quantity to quality of care, providers and physicians are actively looking for ways to eliminate excess spending and improve patient outcomes. One important challenge is care transition – discharging patients from the hospital and continuing their care elsewhere. Providers are seeking better ways to coordinate patient care transitions so as to improve patient outcomes, reduce the cost of unnecessary services, and avoid readmissions penalties.

In a Pitney Bowes Software webinar on Health IT Outcomes, Margot Walthall, VP, Healthcare Solutions at Silverlink Communications and Deb Purcell, Business Solution Architect for Pitney Bowes Software discuss how providers can improve patient outcomes and reduce costs in care transition through data management and integrated communications and analytics.

“Saying that healthcare today is in a chaotic state may be an understatement,” says Purcell in the webinar. “Reform and accountable care is highly political and we’re inundated with positive and negative messages about the goals and hurdles associated with new regulations. In all of the information, it’s easy to be confused about what will really make a positive difference to help achieve the triple aim of reducing costs, improving health outcomes and driving patient satisfaction.”

Care transitions and hospital discharge are particularly difficult, and financial penalties are associated with readmissions. Transitions are often messy, Purcell says. She points out that sometimes care transition isn’t just about moving the patient, but about changing which caregiver is center stage. Further, she observes, “There are many stakeholders and many communication channels, from paperwork to electronic communication via portals and emails, phone calls and even face-to-face discussion.”

Margot Walthall calls out facts and figures from the New England Journal of Medicine Study, which indicates that 2,000 hospitals were penalized in the first year of CMS’ Hospital Readmission Reduction Program.

A solution to the problem, according to the webinar, is the utilization of data management and integrated communications. Walthall discusses the importance of communicating with the patient during care transition and the role that interactive voice response (IVR) technology can play in that process.

Walthall advocates post-discharge phone calls to patients through an automated voice solution. The phone calls ask simple survey questions that trigger red flag indicators. “What this does,” she says, “is allow us to push real-time escalation directly at the care management team that can then respond and follow up with the patient and facilitate the kinds of connections that are appropriate.”

Equally important to care transition management is communication between care team members. Purcell talks in depth about how communication technology can play an important role in supporting the flow of information to provide a more holistic form of care. Referencing McGuireWoods Consulting’s “Five Key Questions to Consider When Forming an Accountable Care Organization,” Purcell points out that at least four of the criteria directly relate to the ability of the care team to communicate with each other.

Given the importance of care management communication, Pitney Bowes Software suggests a framework for addressing the most common care coordination challenges and for identifying the gaps in existing care communication platforms:

• Connect: Purcell talks about the importance of aggregating and integrating data across EHRs and other platforms in order to give caregivers a more comprehensive view of interactions with each patient.
• Orchestrate: Once the data has been identified, the next step is to streamline workflow by incorporating automated communication escalation and trigger capabilities and to support better coordination between different groups of providers.
• Communicate: “After establishing access to the data and the workflow that needs to be supported, the next step is to think about the actual composition and delivery of the message,” says Purcell. This step is about utilizing new communication channels such as IVR, contact centers, social media and more to make sure that all caregivers are on the same page.
• Analyze: Finally, analyzing the communication data can lead to better care outcomes and patient satisfaction.