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With risk migrating from payers to providers, hospitals can no longer afford to cut ties with patients at discharge. Instead, they should actively transition individuals to appropriate post-acute care settings and continually track and assess risk to ensure patients do not return to the hospital unnecessarily.
By taking advantage of the fully embedded discharge solution within Cerner Acute Case Management®, hospitals can create efficient workflows for quick and optimal post-acute placement that reduces LOS, helps prevent avoidable readmissions and, most importantly, improves the patient’s experience, satisfaction and outcomes. Additionally, well-honed discharge processes can mitigate penalties while boosting workflow efficiency and overall care quality – ultimately protecting an organization’s bottom line.
Hospitals that are using Cerner’s EMR (electronic medical record) can enable a cohesive, consistent and reliable discharge and post-discharge experience for patients, their families and staff.
To lay the groundwork for an effective discharge, hospitals should develop a strong education program that engages patients and their families early and often to ensure they truly grasp the patient’s condition. Being a well-informed care participant can increase a patient’s chance of positive clinical outcomes post-discharge, while also enhancing satisfaction.
Before leaving the acute setting, patients and their families should understand the diagnosis, the patient’s expected condition at the time of discharge and the prognosis, in addition to the medications, treatments or therapies included in the care plan. They also need to appreciate their roles in keeping the patient on the path to recovery. Involving patients and families in the process of selecting post-acute facilities prior to discharge helps to engage them in their own care transition process.
By improving not just what information is provided but how it is delivered, hospitals can take their education programs to the next level, making post-discharge care more successful. For example, it is not uncommon for patients to receive paper packets about their condition or care plan prior to departure. Although these packets contain a great deal of information, delivering it in this fashion can be overwhelming to the patient, particularly if he or she has been prescribed new medications or has comorbidities which further complicate the condition. Additionally, it’s difficult to know whether the patient understands or even reads the information conveyed in this manner.
By providing education in different and more meaningful ways, such as during in-person teaching sessions, through videos or via other communication modes like mobile devices, portals or over the phone, hospitals can be confident patients fully comprehend the message. Supporting communications delivered at pulsed intervals help reinforce the key messages and further increase comprehension. Furthermore, enlisting best practices such as the “teach-back” method helps hospital staff reliably assess understanding.
Placing patients in the most appropriate post-acute location can ensure they receive optimal care when they need it. By leveraging care coordination and discharge technology, organizations are better equipped to efficiently and accurately match patients’ needs with receiving facilities’ capabilities and services.
For example, if a patient requires physical, speech and occupational therapy following a stroke, discharge technology embedded inside Cerner’s EMR can be used to identify potential post-acute providers capable of meeting the patient’s needs. Because these can be extensive and include not just clinical requirements but also psychosocial preferences, using this technology makes the matching process much more streamlined and precise. This technology also allows hospitals to provide a targeted list of possibilities to families, informing and aiding decision-making in moments rather than hours or days.
Hospitals that are already using the embedded solution inside the Cerner EMR experience a median response time from post-acute facilities of 30 minutes or less. And if post-acute facilities are slow to respond to requests for referrals, the technology is supported by a 24/7 live customer support center that can reach out to facilities on the hospital’s behalf.
To optimize care coordination and discharge planning technology, hospitals should start discharge planning early – at the time of admission, if possible – ensuring enough time for adequate communication and decision-making amongst the family, hospital and receiving facility.
Supplying meaningful information related to the patient’s condition is key for providing proper care. Whether paper-based or in an electronic format, there’s no doubt health records contain a wealth of information about the patient’s condition and health history; however, comprehensive records can be unwieldy and may even contain irrelevant or outdated information.
For many hospitals, supplying the most relevant information in a timely fashion to a receiving facility can be challenging. But not doing so can delay the administration of necessary medications, treatments or therapies – potentially impacting patient outcomes.
Using Cerner’s embedded discharge planning software, hospitals can extract pertinent information directly from the patient’s Cerner EMR and automatically deliver it to a receiving facility before a patient is transferred, enabling the facility to ready prescriptions, treatments and therapies per the care plan.
Equally important, the software ensures that the appropriate information is transferred; not too little and yet not the entire medical record. Instead, specific information on the patient’s current condition, medications and required care are pulled together into a quickly digestible format and can be sent automatically. The accurate transfer of clinical information helps reduce clerical errors, resolves inefficiencies in workflow and can reduce length of stay, not to mention lower a hospital’s financial risk.
Risk stratification involves assessing and responding to a patient’s risk for returning to the hospital after discharge. Because risk can increase or decrease as patients reach or miss health milestones, hospitals should stratify risk throughout the care continuum – rather than solely upon discharge – and address the changing dynamics of the patient’s condition.
Certain conditions, such as hip surgery, congestive heart failure and chronic obstructive pulmonary disease are more likely to result in readmission. This makes it especially important to monitor these patients’ recovery so the hospital can detect when a patient misses milestones and proactively deploy interventions before the patient returns to the acute setting.
To begin stratifying risk and tracking patients, hospitals can leverage an EMR or other technology with risk stratification capabilities. They should then identify each patient’s preferred communication method and use it to stay connected with the individual, family and/or post-acute facility. Hospitals can also use automated reminders or other outreach strategies to obtain updates as needed.
As healthcare continues to evolve, hospitals need to embrace targeted processes that facilitate patient discharge. Moreover, they must employ methods for monitoring patients after they leave the hospital, allowing organizations to intervene when readmission risk increases.
By elevating and automating the discharge effort, hospitals not only can prevent unnecessary readmissions and ensure patients are transferred to settings capable of meeting their clinical and psychosocial needs, they can also vastly improve the patient’s experience, satisfaction and outcomes while securing the organization’s financial health.