Imagine a patient sustains a heart attack. After the initial intervention to stabilize that person, a care plan is created and the patient is expected to follow a specific set of guidelines.
Traditionally, after the acute recovery period is complete and the patient is discharged, he or she would be instructed to adhere to the plan and sent on their way, with a subsequent consultation scheduled with their cardiologist in the coming days and weeks. It’s likely their family would be given instruction about the diet and exercise regimen deemed appropriate for recovery.
For some, that might be sufficient to trigger the lifestyle changes necessary to avoid cardiac arrest in the future. But for others, that same care plan could be woefully inadequate. The reason being that it fails to take into account the individual’s social determinants of health, their likelihood of recidivism, the expected touch points with the care team, their familial support, their post-acute setting and more.
In today’s world, when readmissions are tied to reimbursement rates and hospitals are being held accountable for what happens long after acute care is complete, those basic, one-size-fits-all care plans simply aren’t good enough. Today’s administrators, nurses and case managers need to conduct careful assessments to determine every patient’s risk factors and evaluate optimum ways to mitigate the dangers of the same, through communication and other forms of engagement.
Even though every patient is unique, crafting these post-acute care engagement plans on an individual basis can be rather difficult given the sheer volume experienced within most health systems. As a result, discharge planners need some guiding criteria with which to categorize patients into varying levels of risk.
Here are the things to look for, with some insights based upon a recent Ensocare webinar in which The Advisory Board’s care management expert Tomi Ogundimu explored “How to Get the Most Out of Your Care Management Model,” including how to properly segment patients.
This is one of the most obvious differentiators and the area where you should start.
Your organization is likely doing this already. If you transition your patient to a nursing home or a rehabilitation facility, you no doubt have created a different care plan than for individuals being discharged to their home, because you know they’ll have access to staff members specifically tasked with overseeing that person’s recovery.
If, for some reason, you’re not distinguishing care plans based on post-acute setting, then this is where to start. At the very least, you need to have decided upon what levels of communication are acceptable. It’s critical that you keep in touch with both the patient and their post-acute care team. That way, you can be alerted to deviations from the care plan and respond appropriately.
The next step is to evaluate patients based upon their specific diagnosis. That starts with acute versus chronic conditions.
For the former, as with the heart attack described above, your goal is to prevent that patient from sustaining additional complications, whether that be a repeat of the original diagnosis or something else entirely.
The successful modern care plan won’t just tell the patient want to do. If your patient has a heart attack and needs to recover, simply listing acceptable caloric intake and exercise isn’t enough. The plan must include touchpoints with physicians and appropriate lines of questioning for members of the care team to use at regular intervals to determine if the directions are being followed. If they aren’t, then interventional measures must be built in. Should the patient’s history and social determinants of health suggest he or she will have difficulty sticking to their rehabilitation regimen, the plan should, for example, provide for a means of attaining financial assistance or delivery of meals to ensure the patient gets the nutrition they need .
With a chronic condition, you need to ensure the patient has the tools necessary to prevent the serious and even not-so-serious ramifications of their condition. If they have diabetes, for instance, an appropriate care plan would take into account their understanding of insulin administration and include any family members who will be responsible for injection should the patient’s own abilities be called into question (for instance, if they have memory issues). Should pick-up from a pharmacy be a problem, the care plan must allow for the inclusion of in-home delivery and the processes surrounding that.
Every condition necessitates a different plan of care, so organizing patients based on their diagnosis is crucial in moving forward.
The Social Determinants of Health
We’ve already hinted at this above in describing the assorted shapes acute and chronic care plans can take, but it bears further examination.
For the vast majority of the timeline of medical care in the United States, a patient was only a facility’s responsibility while they were in the hospital. Once they left, patients were somewhat on their own, barring the occasional check-up from a physician or a member of the care team. At such check-ups, the care team member might counsel those that didn’t follow the care plan, ask them to do better, but then move on.
This format belied a simple truth: patients don’t have equal access to the resources needed to adhere to the care plan. An affluent patient with extensive resources and support systems simply should not have the same care plan as an individual struggling to make ends meet and without any kind of support structure in place.
A care plan that isn’t based on an in-depth assessment of the patient’s social determinants of health isn’t sufficient. If you fail to take these into account, you will have missed at least one factor that could interfere with their adherence.
Here, then, are just some of the social determinants of health to pay attention to and how they will lead to differentiation within the care plan.
- Finance: The individual’s income plays a crucial role in access to medication, care facilities and more. Plans must account for restrictions created by a lack of financial stability, with different strategies in place for persons at varying income levels.
- Transportation: A patient unable to drive is a patient who may struggle to pick up medications and make it to appointments. A care plan must deviate to account for if a person has access to a vehicle, public transportation or ride-share services. In many cases, pick-ups can and should be scheduled by a case manager.
- Location: Is the patient within an urban environment that includes multiple care facilities within a relatively small geographic area? Or do they live in a rural environment where the nearest hospital might be hours away? This must be taken into consideration as well.
- Family Connections: Does the patient live alone or do they have a significant other or adult child who can help them stick to the plan? The plan should differ depending on the availability of someone around to help a recovering individual.
- Technology: A patient who is well-versed in email, texting and mobile apps may have no problem communicating with the care team via your hospital’s patient portal. But someone who does not have that kind of tech-savvy will find it difficult. The plan should have differing means of communication built in based upon the person’s preferences and abilities.
These are just the beginning, and you can see how so many of them are inextricably linked. Individuals living beneath the poverty line may struggle with transportation and access to nutritious food. A person who lives in a rural area could have a tougher time keeping in touch with family or securing transportation than someone in a city.
Social determinants of health weave in and out of one another, creating a domino effect if just a single one isn’t being properly satisfied. That’s why an appropriate care plan is so, so critical.
Modify to Meet Patients Where They Are
Engaging patients through their care plans requires a level of analysis that, until recently, hospitals haven’t consistently given serious consideration.
But by creating patient-centric care plans that take this information into account and combining these with an internal communication plan shared with and understood by the care team, organizations have an opportunity to keep patients on track with the resources they need and out of the hospital.
It may require extensive work, but it will be worth it in the long run for both the patient and the healthcare facility.