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Discharge planning that requires care coordination is incredibly complex. Even with expanding EHR integration, many hospitals today still facilitate patient care transitions manually using fragmented and laborious processes. Rising patient volumes and financial penalties associated with readmissions demand that hospitals implement scalable, fail-proof and efficient processes to move patients between acute and post-acute settings. Technology solutions that provide a broad, engaged network and a service backbone are needed to automate the myriad components of the discharge process, expedite care transitions, improve patient outcomes and result in higher overall levels of patient and family satisfaction.
Automated discharge technology can create efficiencies that decrease the amount of time spent on manual, clerical activities — time that could be better spent interacting with and on behalf of patients. Automation using cloud-based care transition software enables more consistent fulfillment of care plan directives, affords planners more time for one-on-one management of complex cases and provides robust data that can be analyzed to determine post-acute providers’ effectiveness, the incidence of readmission, care transition procedures and their effect on patient outcomes.
Beneficiaries of automated care transition solutions include:
The essential technology required to implement an automated discharge planning solution is minimal. In many cases, there is no capital expenditure for hardware and no software to install. Typical requirements for end users include a computer with a browser and a connection to the internet. Secure, cloud-based Software-as-a-Service (SaaS) models integrate with existing electronic medical record (EMR) platforms such as Cerner or Epic to ensure the continuity and accessibility of a patient’s clinical information. Components of the software streamline document handling, match patients and facilities based on clinical and psychosocial factors, enable electronic communication between acute and post-acute facilities, document patient choice and encourage patient and family engagement.
Increased Oversight Calls for Efficiencies Through Automation
It has taken a surprisingly long time for technology to replace manual processes used in healthcare settings. Meaningful Use was the impetus for many organizations to invest in EMR technologies and, although the EMR created a foundational structure for managing data, many hospital departments remain mired in manual processes that are neither efficient or effective. Technology solutions, much less interoperability of the disparate solutions that do exist, are not as far along in their progressive development as one would hope.
The shift toward a fee-for-value system requires healthcare organizations to perform optimally in the provision of care. No longer are hospitals paid simply to provide services; rather, they must provide verifiably appropriate and clinically effective treatments in order to achieve maximum reimbursement. As part of this movement, hospitals now stand to forfeit up to 3 percent of their total Medicare market basket reimbursement under the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to Acute Care Inpatient Prospective Payment System (IPPS) hospitals if they have a higher-than-expected number of readmissions within 30 days of discharge for six conditions:
According to Kaiser Health News, more than 1,500 hospitals were exempt from the program this year, including veterans' hospitals, children's hospitals, critical access hospitals and psychiatric hospitals. Hospitals in Maryland also were exempt because the state has a federal waiver related to how it distributes Medicare funding. About 80 percent of the 3,241 hospitals CMS evaluated this year will face penalties. The number of penalized hospitals in FY 2018—2,573—marks a slight decline from FY 2017, when Medicare reduced reimbursements for 2,597 hospitals.
The imposition of penalties with regard to avoidable readmissions means hospitals must find better and more efficient ways to care for and maintain oversight of patients beyond the acute care stay. These same departments, once focused on managing manual patient discharge activities that saw the patient to just beyond the hospital door and no further, suddenly find themselves unable to achieve the level of oversight necessary to assure that patients are, for example, following medication regimens, keeping follow-up appointments, eating appropriately or adhering to the most basic terms of the care plan. This becomes even more time-consuming and difficult to achieve when managing patients with complex medical conditions like congestive heart failure, COPD or diabetes.
In response to the need for enhanced oversight, many organizations have attempted to solve the problem by adding more staff. This is neither a sustainable nor effective approach to the problem, as the cost of additional staff may counteract the reimbursement increase that results from reduced penalization.
Aside from the consequence of increased readmissions and the penalties that go along with them, it’s the ramifications for the patients themselves that are most concerning. For example:
There has never been a better time to institute technology solutions that enable consistent and quality healthcare delivery not only during the acute care visit, but also as patients transition to post-acute settings or when they return home. Giving discharge planners and care team managers valuable time back to spend with patients who need them most is better for patients and more rewarding for healthcare professionals.
Stakeholders and Benefits
We have not come far enough in automated discharge technology to fully realize the impact that time saved could have on improving patient outcomes. What we do know is that individuals with chronic illness frequently have a need to navigate the healthcare system but are ill-equipped to do so.
Programs such as Project BOOST and models from Mary Naylor and Eric Coleman track and monitor high-risk patients during the patient transition, although they fall short for longer-term observation and oversight. While healthcare organizations are able to implement these models for small populations, issues arise when the need expands to more patients or those with complex medical conditions. Without the use of enabling technology, these models are often not sustainable or scalable in today’s cost-constrained environment.
Transparency enables performance and quality improvement by providing hospitals and physicians with additional information to benchmark their work. It will obviously assist patients as they attempt to make informed decisions regarding their potential care. Without transparency, there is little opportunity to improve quality and efficiency among providers, patients and their families.
The benefits of automated solutions to process-related problems such as care coordination extend to all hospital stakeholders. The potential value of implementing an automated discharge solution can be attributed to four primary categories including: 1) mitigation of risk (financial); 2) clinical (patient outcomes); 3) efficiency; and 4) patient satisfaction. While the benefits do cross boundaries, the following illustration shows how each stakeholder group stands to gain when enabling technology replaces manual processes for transitions of care.
Using A Technology Solution to Resolve Manual Effort at Key Points in the Discharge Planning Workflow
Workflow fragmentation is inherent to the process of patient discharge. Healthcare professionals must manage multiple processes using varied methods to move patients between points A and B. Even with an EMR in place, it is common for care transitions to involve little in the way of electronic dissemination of information. Instead, they rely heavily on manual processes that use fax machines and telephones to make essential connections.
To better illustrate the impact technology can have on overall discharge workflow efficiency, consider the following illustration. Shown are essential steps involved in the complex process, each requiring varying degrees of time, effort and manpower. These steps illustrate a typical discharge workflow moving a patient to the next level of care.
At least 24 manual steps can be eliminated by introducing an automated discharge solution. By removing the steps that once required manual effort and by automating the process to eliminate potential points of breakdown, care transitions can be more efficiently and systematically managed.
The Efficiency Improvement Assessment
A hospital can carry out the essential steps of the discharge process manually or by leveraging technology. Although hospitals can see benefits from either approach, employing technology can greatly increase the scalability of interventions. Ensocare reports that hospitals moving from a manual to an automated discharge process, for instance, can see LOS reductions of up to one full day for patients going into post-acute facilities. Because a vast majority of reimbursement — especially Medicare — is set by diagnosis, this improvement can substantially affect an organization’s bottom line.
Ensocare is a SaaS provider that offers one automated discharge solution sold primarily to hospitals, health systems and ACOs. Existing and potential verticals also include the payer and government (VA) markets. Ensocare has four software engines designed to solve inefficiencies and potential points of care coordination failure before, during and after patient discharge, with a unique backbone that differentiates it from other existing automated solutions. Specifically, it maintains a highly engaged, no-cost, nationwide network and provides 24/7 live customer support that assists and drives activities of both the acute and post-acute stakeholders.
Statistics gathered by Ensocare, coupled with data from the American Case Management Association (ACMA), were analyzed to illustrate the efficiency payback from using a technology intervention for care transitions. These industry benchmarks can be used to measure and assess discharge planning activities from the standpoint of time and efficiency.
For example, Ensocare’s data show that planners conservatively spend an average of 30 minutes on the phone per each discharged patient (or “case”) and another 20 minutes preparing to send a case to post-acute providers for consideration, acceptance or denial. Using these and other reported averages from the ACMA Survey, a cost-benefit scenario can be calculated to determine the cost of discharge activities and the potential for efficiency improvements. The steps saved by implementing automated discharge add up to real savings in time, efficiency and manpower.
Using the sample inputs provided for a hospital with 8,625 annual discharges and 12 FTEs managing discharge activities, a calculated 12 hours per week (per planner) is spent handing clerical activities such as faxing documents, answering phone calls or searching post-acute options. This number decreases to one (1) hour per week per planner when an automated solution is enabled.
Looking at these statistics from another angle, 29.9 percent of a planner’s work week is currently spent performing clerical tasks such as those previously described. This is time spent conducting activities separate from one-on-one patient care or consultation. After automation, this percentage drops to 3 percent.
Finally, applying the ACMA salary averages to these calculations, the hospital in this example stands to save $201,502 annually in efficiency.
Although the example shown is hypothetical, the actual ROI that results from redirecting clerical efforts and eliminating inefficiencies is not. Ensocare reports findings from one Midwest-based medical center that examined how implementing automated discharge technology affected business. After measuring for six months, the organization observed a significant LOS impact for post-acute handoffs. Specifically, LOS for patients discharging to skilled nursing facilities dropped by 5 percent; home health agencies by 12 percent; and acute rehabilitation hospitals by 8 percent.
Essential Qualities of a Cloud-Based Automated Discharge Platform
When it comes to automated discharge technology platforms, not all are created equal. It is advisable to look for some key qualities when comparing existing SaaS-based solutions:
Interoperability and ease of integration with existing EMR platform – Just because your organization has a “name brand” (or off-label, for that matter) electronic medical record system doesn’t mean it will play well with every automated software solution on the market. Look for options that offer real time, bi-directional data exchanges between disparate platforms and are able to work in concert with health information exchanges (HIEs). Also realize that some EMR platforms may already offer add-on or available discharge technology options. Cerner, for example, offers an embedded version of Ensocare’s solution to its Cerner Millennium® users. Find out what is available and carefully examine interoperability options.
Highest Level of Security – Today’s healthcare landscape demands that any system, software or otherwise, that handles sensitive patient information must include the highest level of security possible. Look for companies that invest in cloud security that aligns with the National Institute of Standards and Technology’s (NIST) Cybersecurity framework. For government entities, AWS GovCloud or FedRamp security is likely required to secure transactions dealing with patient records.
Availability of a nationwide provider network NOT based on “pay for play” criteria – While it may be tempting to set up a “narrow network” of providers, one that is all-inclusive is far better. Forcing providers to pay a fee to a network in order to receive electronic referrals can limit provider participation and your patients’ options. Look for a solution that offers a network that spans across the nation, not just down the road or around the corner.
Engagement of the post-acute provider network – Engaged providers respond faster, which means your patient promptly gets to the right place the first time. For example, by providing the technology and allowing post-acute providers to receive referrals electronically at no cost, Ensocare has realized an industry-leading 80 to 90 percent participation rate, driving the referral acceptance response time down to a median of 30 minutes. Further, a robust referral network yields valuable referral placement data that, when combined with admissions data, lends itself to trends and performance analytics that will become useful in the fee-for-value environment.
Availability of 24/7 customer support – No one likes to receive a “press one for an operator” message, and this is especially true when seeking post-acute placement for a patient. Stress on staff can be reduced by ensuring the automated discharge solution is supported by an active and available support network. An active support network also serves to continuously monitor response times of client networks. Providers who do not promptly respond to referral requests are contacted to investigate delays and activate and motivate the network.
Automated discharge technology offers healthcare organizations a relatively low-cost, scalable and sustainable option for facilitating care transitions that minimize both clinical and financial risk. The efficacy and applicability of such software is contingent on key factors such as the volume of annual discharges, the incidence of patient co-morbidities within the patient population served and interoperability issues with existing technology implications.
See below for bibliography.