Ensocare - Topics on readmissions, discharge process and improving patient care

Post-Acute Transition Strategy in an Era of Uncertainty

Written by Justine Olsen | 12/20/17 8:45 PM

An inside look at how discharge teams can be a driving force in helping health systems achieve value-based care objectives.

Healthcare reform has been at the forefront of national attention throughout 2017. 

Having gained majorities in both the House of Representatives and the Senate during the 2016 election, the GOP and Trump administration began the year with a priority to make good on a seven-year promise to “repeal and replace” the Affordable Care Act. To date, however, the GOP has been unsuccessful in attempts to pass legislation to fundamentally overhaul key provisions of the Affordable Care Act.

Uncertainty regarding the short-term future of healthcare reform has likely been more destabilizing to the healthcare industry than passage of any legislative reform would be. Yet in spite of this uncertainty, the shift toward value-based care can provide the stability needed for meaningful strategic planning efforts.

Industry-wide support exists for the continued shift toward value-based care, i.e. reimbursement based upon demonstration of quality and cost-effectiveness. This has prompted acute care facilities to focus on key metrics like total cost of care, patient readmission rates and patient lengths of stay. Implementing processes that foster effective patient transitions from acute care to post-acute care settings represents an opportunity to promote achievement in these metrics.

Two areas of focus – active incorporation of “patient voice” in the discharge planning process and standardized communication between acute care and post-acute care facilities – can help promote effective patient transitions to step-down care.

Incorporation of Patient “Voice”

Patients and their caregivers represent critical members of the care team. Adopting an “active listening” mentality can help acute care staff identify barriers that, if unaddressed, could hinder patient success post-discharge.

Prompts can be used to start a dialogue with patients and caregivers regarding personal priorities related to post-acute care. Concerns expressed during such dialogue can elicit pre-discharge action steps responsive to the patient’s post-acute choices. 

The following examples demonstrate how an active listening prompt can spark discussion that directly influences post-acute services arranged prior to discharge: 

  • “What are the two most important characteristics of the facility you will stay at when you are discharged from the hospital?” 

The answer to this question will help acute care staff understand patient priorities regarding post-acute care placement. For example, a patient who wants to remain in close proximity to his or her caregivers may prioritize geographical location over facility amenities.

  • “What worries you most about being discharged from the hospital?”

This will help identity the types of non-clinical concerns that commonly lead to non-compliance with patient care plans. For example, a patient who is most worried about the affordability of home health or physical therapy may forgo or limit services if a reasonable solution is not identified prior to discharge. 

  • “We have talked a lot about your medical condition and the follow-up care you’ll need in order for you to feel better after you are discharged from the hospital. I want to make sure you understand your medical condition and what you will need to do every day to help manage your condition and continue to get well. Can you tell me what you understand about your medical condition? Can you tell me about your medications and how you should take them in order to be well?”

The dialogue that results from these prompts can help acute care staff pre-emptively identify and address gaps in understanding that may affect issues like medication management. By inviting the patient to, in essence, educate the provider based on their understanding of their condition, the care team can be confident in that person’s ability to adhere to the care plan. Furthermore, it invites them to become advocates for their own health after they’ve been discharged.

Incorporation of “patient voice” can help promote placement in a facility or service best aligned with patient priorities and needs. Such alignment encourages adherence to patient care plans and, in turn, likely influences outcomes. 

Standardizing Communication across the “Medical Neighborhood”

Acute care facilities must make concerted efforts to continually strengthen working relationships with the post-acute facilities and providers where they most frequently refer patients. This “medical neighborhood” approach recognizes the importance of cultivating partnerships (whether formal or informal) across the continuum of care, with an explicit intention of improving care coordination. 

Standardizing communication expectations between acute and post-acute care facilities represents a critical component of care coordination. The following prompts can be utilized as a first step in developing such standardized expectations: 

  • “What facilities and providers do we (the acute care hospital) most commonly work with to coordinate care of a discharging patient?”

These facilities constitute your “medical neighborhood.”

  • “What processes are currently in place to communicate with facilities and providers in our medical neighborhood?”

These processes represent your baseline performance regarding care coordination. Aim to bolster existing communication efforts. This should extend beyond maintenance of a referral directory.

  • “What barriers exist during the referral process that, if addressed, would improve care coordination across our medical neighborhood?”

Focus on implementation of the top two or three low effort, high reward activities. 

For example, if “phone tag” consistently delays the patient referral process at a post-acute care facility in your medical neighborhood, consider electronic communication or an automated system to streamline referrals. If response time or incomplete documentation consistently delays the patient referral process, consider establishing formal MOUs (Memorandums of Understanding) with post-acute care facilities in your medical neighborhood. These MOUs should outline expectations regarding responsiveness and methods of information sharing. Reinforce compliance with the MOUs by facilitating intermittent status checks to evaluate performance. 

Optimizing your workflows with an eye toward standardization of communication is a promising practice that could improve coordination as patients transition to step-down care.

2018 and Beyond

It’s impossible to predict what happens next in the ongoing battle over healthcare reform. But by centering post-acute planning efforts around the value-based care model, specifically through listening to patients and standardizing communication, you’ll be ready to adapt to whatever 2018 has in store for healthcare.