White Paper

    Digital Care Plans: The Next Step in Preventing Readmission

    The Teach-Back Method is old hat.

    Deployed by countless hospitals, the teach-back method is a long-accepted way of care plan adherence that involves explaining the prescribed post-acute care regimen to the patient and then having the patient repeat it back to the hospital team member detailing the plan.

    While certainly a more beneficial form of learning than passing the patient a pamphlet and wishing them luck, the teach-back method should only be considered step one in a modern care management process.

    An ideal modern care plan is a fully digital mechanism that can live on a Smartphone, a web browser or a wearable device, supplementing the on-site teach-back method with ongoing coordination between patient and care team.

    In the following Ensocare White Paper, you'll see how leading hospitals are utilizing digital care plans to greatly improve the patient experience and reduce the risk of readmission, thanks largely to unprecedented customization options and myriad opportunities for leading-edge patient management. You’ll also see how communication plays an increasingly important role in the refinement of care plans. Finally, you’ll see how discharge has gone from an “in one ear and out the other” experience to an ongoing conversation between patient and care provider that plays an integral role in improving outcomes, access and satisfaction while reducing costs.

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    Proven Templates

    There’s no need to create care plans from scratch when certain best practices are readily available for the most common diagnoses.

    Care plan software like that created by our partners at Wellpepper comes with digital care plan templates created from input by physicians and other experts in the fields of medicine, rehabilitation and wellness. These templates address typical post-acute conditions using commonly prescribed methods of recovery and therapy proven out by research and honed to fit modern standards of care.

    That means post-acute digital care plans are available for things like:

    Digital Care Plan PossibilitiesPerhaps the best part about such templates is that they’re not set in stone. While you can certainly implement a digital care plan that’s been fully prebuilt, you can also edit them to fit your practice needs. If you’ve found that a diet or exercise regimen is better suited to your patients, custom care plans can be created to reflect your own best practices, then saved for future use.

    Care Team Communication

    So far, we’ve only addressed one side of the care plan communication spectrum. But there’s also a second component of the modern care plan that’s important to note, and that’s the increased attention to dialogue between patients and providers as well as between providers themselves.

    This dialogue takes two primary forms.

    1. Messaging

    The ability to instantly ask questions and receive an answer quickly is critical to helping patients adhere to care plans, and it’s only going to become more important as the generations who grew up with text messaging, Smartphones and social media require more care as they age.

    Messaging via a secure EHR portal is crucial, as it takes the teach-back method to a whole new level. Imagine a patient who identifies a point of confusion and just wants to ask a simple question via their app rather than go through a series of cascading phone menus to speak to a human.

    What’s more, it’s possible to identify the message using machine learning in order to identify its relative sense of urgency. For instance, an all-caps subject line with the words “HELP – INSULIN MISHAP” may get routed directly to you as an instant notification on your phone, whereas a subject line that says, “Can I eat shellfish?” from your non-allergic knee case can probably wait awhile.

    In this way, providers receive the notifications they need in order to help patients, and they can message those patients back based on urgency and the patient’s preferred method of communication.

    Digital Messaging Prioritization2. Patient Notifications

    Of course, there’s a second side to that coin as well, and that’s the notifications deployed to patients.

    Some of these can be obvious. You can set up reminders for a patient to take their medication at a certain time each day, schedule alerts for one hour prior to an important appointment and even alert the patient if you’ve decided their level of recovery thus far warrants an alteration to the previously agreed-upon care plan.

    But let’s go further than that. It’s possible with digital care plans to actually differentiate messaging based on the patient’s relative adherence to the therapy.

    Let’s say you have Patient A. They record their vital signs, they show up to their appointment and it’s clear based on their recovery that they’re engaging in the movements, exercises, diet and other directives you’ve requested of them.

    That patient probably isn’t going to require constant attention. And if you do want to communicate with them, you can schedule a simple “Great job!” or email them rather than interrupt their ongoing habits.patient-a-phone

    But then there’s Patient B. Patient B, while well-meaning, regularly forgets to update their vitals in their prescribed wearable device, they live in a food desert that leads to a relatively poor diet, and their condition combined with a lack of attractive transportation options means they have trouble getting to appointments.

    For Patient B, you may thus need to take a more hands-on approach. That might mean regular phone check-ins from a case manager or SMS messages to ask them if they need help with anything. You wouldn’t scold them, but you probably would set up reminders using the communication channels you know they’ll interact with.patient-b-phone

    These notification settings, which are adjustable over the course of time depending on your preferences and your patient’s needs, are another key benefit of digital care plans.

    Patient Surveys for Ongoing Refinement

    Finally, surveys of patients at key junctures within their recovery provide an exceptional viewpoint into the success of the care plans themselves.

    Deployed electronically using nationwide standards (KOOS, ASES, Roland Morris, and others), digital surveys allow you to check in with your patients to gauge their thoughts on whether the care plan has set them up for recovery and long-term success. What’s more, once you collect enough data from your patients, you can analyze this information to see what’s working well, where patients may exhibit adherence issues, which prescribed therapies are not working as well as intended, how patients reacted to your ongoing communications and more.

    These surveys are the final component to a successful digital care plan, and they ensure you can look at every link in the care journey and make changes as needed to provide optimum care for your patients.

    The End Result

    So what does this all mean? We’ve discussed the benefits of supplementing discharge with a seamless digital care plan, but what about the impacts it can have?

    When the patient is quickly discharged home or to a post-acute facility that has precisely the therapies they need to maximize their chances for recovery, and that first successful transition acts as a launchpad to a connected, high-touch-point digital care plan, hospitals and patients alike benefit in four distinct ways.

    Improved Patient Outcomes

    Perhaps the best result of deploying digital care plans is the most blatantly obvious, and that’s improved outcomes for patients.

    When you can reduce the risk of misunderstandings via straightforward explanations and reminders about prescribed therapies, send alerts to nullify the effects of confusion or forgetfulness, and strengthen the overall dialogue between patients and providers, it simply makes sense that improved patient outcomes will follow.

    This is critically important for any facility concerned about patients being readmitted 30 or 60 days following discharge. By improving the care plan, you can improve outcomes and drastically decrease the odds that a patient will wind up back in the hospital with complications from the procedure for which they were originally checked in.

    Patient at Home on PhoneLower Costs of Care

    This then leads to the next benefit, which is savings for your facility.

    Because you’ve reduced the number of patients being readmitted, you’re also reducing the applicable reimbursement penalties such readmissions would trigger under the value-based care model. And with improved satisfaction scores based on the patient surveys that come with the digital care plans, you further increase your financial viability if your Medicare Part B payments are adherent to the Quality Payment Program developed under MACRA.

    Because you’ve optimized your resources to get precisely the communications to patients that you need them to see, when you need them to see it, you’ll also experience cost-savings associated with the intensive labor needs of overall care management.

    Digital care plans save your own team members time and money because they can focus their efforts on high-acuity patients with complex problems rather than requiring those same staff members to sift through data and route all incoming requests manually, regardless of acuity level. With digital care plans, patients most at risk for readmission are prioritized while low-risk patients can be managed more efficiently through the app.

    Increased Care Access

    Because digital care plans bring the patient in closer contact with their providers, their access to the types of care that can prevent readmission grows exponentially. You can easily identify at-risk patients and then work with them to help them address their greatest challenges.

    That could mean scheduling appointments, transportation, food and medication deliveries and more, then following up the scheduling of these episodes with 24-hour and one-hour alerts that ready the patient for these same appointments/deliveries. This addresses the social determinants of health that have eluded hospitals’ scope for so long, the end result being that people who never had access to a premium level of care are finally able to adhere to care plans that had heretofore proven difficult if not impossible to follow.

    Increased Satisfaction

    Finally, all of this adds up to one unassailable benefit: patients are happy. Freed from the constraints of confusing medical lingo and an inability to contact the care team in expedient fashion, patients no longer have to look at their recovery as a challenge to be surmounted. They can see the benefits the care plan has on their health while simultaneously being in closer contact with their providers than ever before.

    This satisfaction is made possible thanks to digital care plans that take automated patient discharge to its next logical step. By automating not just discharge, but the very foundation of post-acute care in a way that makes the most sense for patients and providers alike, it’s possible to rethink healthcare entirely.

    Learn More About Implementing  Digital Care Plans at Your Facility!


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