Managing Risk During and After Patient Discharge

by Luis Castillo on Aug 1, 2018

riskfactorNo matter who your patient is, there’s no way to avoid a certain degree of risk. If there were, preventing readmissions would be a much easier prospect.

But even if we can’t eliminate risk entirely, we can certainly manage it. What we’ve discovered when traveling to hospitals across the country is that, try as they might, few organizations have the bandwidth to fully mitigate the common and not-so-common threats that impede an individual’s successful recovery.

Typically, the lack of risk management capabilities has to do with one of three factors. If your own facility doesn’t suffer from one of the following, then you can consider yourself among the lucky few. But I’m willing to wager that almost all of you have encountered one of these dangers:

  1. Budget constraints
  2. Labor shortages
  3. Communications gaps

Today, I want to focus on how software can be used to address point #3 and help you eliminate the communications gaps that lead to greater risk. There are 4 key ways to harness health IT to manage risk both during and after the patient discharge process, and all of them rely on opening up lines of communication between providers, payers and patients themselves.

Reduce Wait Times for Discharge

NW_DischargeOne of the greatest risks to a person’s wellbeing, and something that certainly impacts a hospital’s bottom line as well, is the length of time an individual must wait prior to being discharged from an acute care setting.

The longer an individual remains in acute care, the greater the risk of infections, relapses and other accidents that could have been avoided. The time it takes to oversee that patient’s continued recovery and manage their discharge puts a strain on your resources and puts reimbursement at risk, not to mention having an unavailable bed that should be going to the next patient in line.

In order to reduce length of stay, it’s vital to use everything at your disposal to communicate with post-acute providers and transmit patient packets as quickly as possible.

That’s no small task, especially when you may need to communicate with dozens of facilities in order to find one that has a bed available, offers the treatment necessary for that patient and is included as a provider under the individual’s insurance plan.

Technology holds the answer. The Ensocare Transition tool, for example, can send the patient clinical packet to the most appropriate facilities almost instantly, and the response that comes back can arrive in a matter of minutes. The system can automatically send electronic packets or faxes without you ever having to approach a fax machine yourself.

No more placing a ton of phone calls, waiting by the fax for an answer, or jumping through hoops to get a response about your patient. Using this technology paired with Ensocare’s professional call center to keep the network engaged and responsive has been shown to reduce length of stay, thus reducing both clinical and financial risk.

And that’s only the beginning.

Provider CoordinationPAC Provider on Phone

As long as communication barriers remain up between acute and post-acute providers, risk will exist. Barriers create assumptions that lead to serious and sometimes grave errors.

Case managers are crucial in keeping track of a patient’s ongoing care once they enter the post-acute space. Again, technology is the answer, and Ensocare Sync has been designed with this need for communication in mind.

When all care touch points, including appointments, medications, expected recovery schedules and treatment options, are united under a single digital roof, communications gaps are removed at once. Any member of the care team has the ability to review the available information as a snapshot of the patient’s recovery at any given time.

A case manager can check in on not just patients, but on post-acute partners, physicians and assorted other care team members at regular intervals. He or she can spot potential areas of risk and respond by either contacting the patient directly or routing the necessary details to the care plan member of choice, so an intervention can occur before the problem escalates.

Let’s say an alert goes out that shows missing information for a rehabilitation appointment. The case manager can and should message the physical therapist to see what’s going on. It could be a matter of accidental oversight where the physical therapist neglected to put the details of the appointment into the system. Or the patient may have missed the appointment, which then signals to the case manager that they need to get in touch with the patient or the patient’s family. This conversation could reveal a lack of appropriate transportation, which then signals to the case manager to get in touch with a rideshare service to set up rides at the necessary times.

With Sync, all of this can happen in a matter of minutes as opposed to the hours these same steps previously would have required. This shows how a minor issue can balloon into something major, but it also demonstrates how a case manager, using technology, holds the key to reducing the risk entirely.

Payer Engagement

The final piece of the puzzle, and one that can’t be neglected in today’s healthcare landscape, is collaboration with payers.

Payers are all about minimizing risk. After all, they’re the ones who are ultimately on the hook for payments when a patient’s discharge and recovery don’t go the way they’re supposed to.

Right now, payers are doing everything in their power to identify post-acute organizations that meet certain quality metrics and developing narrow networks based on those criteria. With readmissions penalties arising due to Medicare changes, the development of a narrow network of high-performing post-acute providers is something that hospitals also need to look at.

Reach out to payers. If they’ve partnered with a certain post-acute facility but dropped another one, you need to know why. This is going to improve your own care practices as you’re tipped off to issues that otherwise may have remained outside your purview. We all want what’s best for patients and we want to achieve that goal in a way that makes care affordable for patients, providers and payers alike.


The final key to managing risk is harnessing available data to identify the biggest threats to your patients.

Big data is big in healthcare IT, and it’s easy to see why. A physician dealing with a relatively small handful of patients can garner certain insights about patterns of care, but their scope is limited. An overarching, artificial intelligence-powered algorithm overseen by a clinical informaticist who has the data from every patient in the last decade can provide far more insightful and impactful conclusions.

AI and informatics are transforming the healthcare landscape. The sheer amount of information available is creating insights that wouldn’t have been possible even a few years ago. If you can align those insights with those of post-acute providers and payers, you’ll arrive at actionable findings that have a real impact on patient care. With a data-backed approach that has the support of all parties, healthcare entities can create population-specific workflows that emphasize the precise type of care, the right moments for a care team member to intervene, and the resources the patient requires in order to have the best chances at recovery.

You can do a lot by reducing length of stay, communicating with post-acute providers and collaborating with payers. Adding the insight that data can provide will help bring everything together to intelligently manage risk long into the future.

Ensocare Sync and Connect

Meet the Author

Luis Castillo has more than 30 years of experience in healthcare information technology. Prior to joining Ensocare, Castillo served as senior vice president at Siemens Healthcare, where he was in charge of IT sales, service and marketing. He was responsible for developing alternate markets, sales strategies and sales channels in order to grow the healthcare information technology business. Luis’ broad and deep experience has served to hone his leadership skills and business acumen, and he is a sought-after participant in strategic initiatives and global partnership efforts. He earned his Bachelor of Science degree in political science from Haverford College in Haverford, Penn.