By Kyle Salem, Managing Director at CQuence Health Group and Ensocare Member of the Board
With the proliferation of high-deductible health plans, patients have a greater financial stake in their care than ever before — in some cases paying thousands of dollars for a single care episode. Likewise, hospitals are taking on more financial risk for patients beyond the hospital stay. Programs like the Comprehensive Care for Joint Replacement Model (CJR) and the proposed rule for cardiac bundled payments put hospitals at financial risk for managing the quality and efficiency of care delivered throughout the care episode and during the 90-day period after the patient leaves the hospital.
The increased financial responsibility on the part of all stakeholders, coupled with a general growth in healthcare consumerism, is prompting hospitals and health systems to take a closer look at the patient experience.
One especially vulnerable area relates to care transitions. When patients move from one care setting to another, the experience is often complicated and fragmented. Insufficient communication plus a rushed dynamic results in inefficiencies, gaps in care, and missed opportunities to optimize quality and be compassionate. The entire process can be stressful for patients, not to mention expensive and clinically risky.
Care transitions do not have to be this way. By rethinking the way patients move from one stage of care to another or from one physical care location to another, hospitals and health systems can ensure they are more proactive and patient-centered. The following are a few key communication touchpoints and simple process best practices for reimagining patient transitions.
Empower Patient Decision-Making
For many organizations, the discharge process begins when a case manager gives a patient and family a standard list of possible post-acute options, asking them to select where they would like to go for post-discharge care. This can cause the patient and family a great deal of anxiety as they struggle to understand various facility offerings, how much they cost, and whether they would be a good fit. Frequently, the list is presented with a strict deadline for selection not leaving sufficient time to make a well-informed decision, thus patients and families feel frustrated.
However, by putting systems in place that define ongoing care and ensure timely communication across settings, organizations can not only streamline discharge but improve the patient experience in the process.
For example, when hospitals are equipped to help patients and their families select the most appropriate provider placement, uncertainties can be relieved and a higher quality of coordinated care ensured. Electronic care coordination solutions, for instance, are able to automatically decrease a list of potential facilities to include only those that meet the clinical and personal needs of the patient, simultaneously contacting the organizations to determine if they can accept the individual. This allows the case manager to generate a comprehensive, yet narrowed-down, list of facilities that are most capable of addressing a patient’s unique requirements.
Using additional technology, staff can even provide patients with a virtual tour of various facilities, further assisting patients by giving them a chance to “see” the different choices. In an already emotional time, this degree of focused attention can ease anxiety and give individuals a sense of control. Moreover, it can help patients select the most appropriate facility for their needs.
Perhaps even more important, automated care transition solutions provide a communication platform through which care teams, patients, and families can maintain ongoing communication far beyond the actual episode of care. This can provide the oversight needed to identify declines in health, medication compliance problems, missed appointments or other important indicators that could signal a potential relapse and/or rehospitalization.
Prevent Unnecessary Delays
Oftentimes, discharge planning begins just before the patient is released from the hospital. However, by starting things earlier — almost as soon as a patient is admitted and physicians determine he or she will need post-acute care — organizations can allow plenty of time for the patient to vet different post-acute options. This means when the individual is ready to leave, the decision on the next care setting has already been made, the post-acute organization has been notified, and information exchange has already begun. Being proactive in the process ensures the patient remains in the hospital only as long as necessary, avoiding extra days sitting around waiting. This shortened length of stay is more cost effective for both the hospital and patient, and is less traumatic because patients are not continuing to remain in a facility when they don’t have to.
Improve Information Exchange
A common shortfall in care transitions is limited information sharing between the different settings. Much of this issue is brought about by existing EHR platforms that were not designed with interoperability in mind. It is not unusual, for example, for a recently discharged hospital patient to arrive at a long-term care organization carrying his or her medical record. Not only is the record unwieldy and difficult for the long-term care organization to navigate, it is arriving at the same time as the patient, so there may be care delays as the post-acute facility tries to get up to speed. In the worst case, the receiving organization may miss care steps altogether, which can negatively affect the patient’s health.
Using automated discharge tools, hospitals can electronically share the most relevant patient information with the receiving facility prior to the move. This enables a seamless onboarding experience because the receiving facility can prepare orders for therapy, medications and other treatments before the patient arrives.
When patients are matched with the right facility, and communication between the hospital and receiving organization is effective, it prepares the patient for the best possible care. This limits unnecessary hospital readmissions, which are a huge patient dissatisifier. Keeping patients out of the hospital avoids an added financial burden, reduces stress and allows patients to recover faster and get back to their normal lives.
There’s No Time Like The Present
As hospitals take on more risk, they must start building the infrastructure to manage that risk — not just when patients are in the hospital—but also for the period of time after hospitalization when oversight is mandated. Having a system in place to define care and enable swift and comprehensive communication across the care continuum will not only protect the hospitals’ financial interests, but also ensure appropriate care for patients as they cope with potentially chronic health conditions.