The reality of reform is harsh. In 2015, 2,592 hospitals were penalized to the tune of $420 million dollars for patient readmissions.
To attack the readmission challenges that hospitals face, you must first understand and solve the discharge challenges. The point at which the patient transitions from the hospital to the next level of care is a mission critical point.
The recently proposed Centers for Medicare & Medicaid Services (CMS) discharge planning regulations present an opportunity for hospitals and other health-care providers to improve the discharge process. With the proposed regulations, hospitals are faced with the need to:
- Provide better communication and coordination with disparate providers and facilities
- Accurately determine the level of readmission risk of a patient as well as specific areas of concern
- Move patients as quickly as clinically appropriate to a lower level of care
- Provide both clinical and non-clinical services to keep the patient well
- Maintain communication and patient status at the patient’s care facility, home or other service location
Most discharge planners today don’t have the time, technology or relationships to achieve these goals. They are challenged by too many clerical tasks, too small of a post-acute provider network and not enough time to assess and address patient needs—notwithstanding the lack of capability to track patients after discharge. But by leveraging technology, organizations can enrich communication between providers, streamline referral activities and fully meet patients’ needs before and after they leave the hospital.
For starters, the use of enabling technology can connect the hospital and post-acute care facilities involved in the patient’s care. This opens up real-time, multi-directional communication between all stakeholders and closes several gaps. Care coordination and communication can now be seamless as the patient moves step by step through the care continuum despite the multiple handoffs and disparate IT systems.
It is imperative for hospitals to enhance risk mitigation strategies especially as value-based payments continue to impact reimbursement. And as we all know, hospitals already operate on razor-thin margins so supplementing staff to monitor patients after discharge is not sustainable. Employing risk stratification technology to provide continuous anywhere-anytime monitoring coupled with real-time health data integration from wearables, apps and other mobile devices is a much more scalable and affordable solution.
With this model, critical biometric data or noncompliance with the care plan can automatically trigger alerts to the appropriate care team member and allow for as-needed interventions to occur before the patient’s problems worsen. This has a direct impact on improving quality outcomes and reducing readmissions.
The combination of enabling technology and risk stratification provides organizations the opportunity to precisely pinpoint which patients have the greatest likelihood for readmission and follow-up with more intense observation, monitoring and high-touch interactions. For the less at-risk patients, organizations can then rely on automated oversight, monitoring and follow-up.
Moving patients to the clinically appropriate next level of care is a process with high potential for errors to occur for several reasons. Without automation, it is a lengthy process that requires making phone calls, manually “farming” information from the EMR, faxing patient medical records and then making numerous follow-up calls to get a referral response. Hours or days can go by with valuable time wasted on the phone or fax. How can we expect the discharge planner to match and place each patient with the right facility to care for each individual’s overall needs?
The next problem is that quality and quantity of patient information that organizations exchange at discharge varies significantly. On one end of the spectrum, a hospital may supply very little information to a post-acute provider; on the other end, it may send a copy of the entire medical record with the patient, overwhelming the receiving care provider. Neither option is acceptable, and discharge planning software is one solution to achieve a happy medium. It can auto extract from the EMR the specific information on the patient’s current condition, medications and required care.
With one push of a button, the hospital can then send this data electronically to all clinically qualified facilities in a quickly-digestible format. There are hospitals today using electronic referrals who experience a median referral response of 17 minutes. Not only does the patient get discharged quickly, the receiving facility has all the information it needs to start therapy and appropriately care for the patient, ensuring there are no lapses in care or delayed or duplicated treatments. This has a significant impact on reducing clerical tasks, inefficient workflows and length of stay.
Not every patient released from a hospital will need to go to another health-care facility; in many cases, a hospital sends a patient home. However, this individual may still require services, such as meals, regular blood pressure checks, physical therapy, medication refills and so on.
Historically, hospitals have not been able to reliably connect patients with appropriate community resources. In the best case scenario, a hospital supplies the patient with a pre-printed resource list, encouraging the family to reach out to the providers on the list at their convenience. However, by embedding community provider information into discharge planning technology, hospitals can proactively reach out to both clinical and non-clinical resources electronically, matching patients with suitable organizations and lining up all the needed services before the individual leaves the hospital.
The newly proposed CMS regulations strongly emphasize the importance of taking the patient’s clinical needs, care goals and psychosocial preferences into account when planning for discharge. If organizations place the patient at the center of the planning process, they will improve patient outcomes, enhance satisfaction, reduce costs and limit the likelihood of medical errors and unnecessary readmissions.
Lastly, in order to maintain communication and oversight of the patient’s status whether at the post-acute care facility, home, or other service location, we come full circle to where I first started—with using enabling technology to connect everyone in real-time throughout the continuum of care.
Download our white paper to learn five fundamental tactics to reduce risk during care transitions.