Insights

Introducing the Post-Acute Care Continuity Plan

by Mary Kay Thalken, RN, MBA on Jul 5, 2018

Outpatient Care Using TabletThe push for care coordination improvement, penalties for avoidable readmissions, and consumer adoption of intelligent technologies are trends entrenched in the practice of care. All three are reshaping the healthcare landscape based on one simple fact: It’s much less expensive for a patient to embrace self-care strategies to treat new or recurring symptoms than to end up in the hospital. Otherwise, hospitals and health systems will face even greater challenges transitioning to value-based care.

The solution involves a two-part strategy:

  1. Introduce a self-care post-acute care continuity plan that expands beyond the hospital and is entirely e-transaction focused
  2. Maintain patient oversight at home or other post-acute care setting through a connected care team

Beyond the Traditional Discharge Plan

In addition to moving patients from the hospital to the next level of care – long-term acute care, skilled nursing, assisted living, home care, or rehab – providers must expand the traditional discharge plan to help patients navigate the post-acute care transition. In other words, provide the new care management experience of “being connected.”

Specifically, this approach requires new ways of thinking and innovative connectivity tools that engage the patient, family members, and loved ones to encourage proactive self-care measures.

To that end, the post-acute care continuity plan can offer in-home wearable technology as part of the patient’s self-care discharge strategies. The ideal plan would enable the patient, family, and caregivers to connect with a team of clinicians who can monitor health statistics and communicate remotely without extensive oversight. No longer must a patient be confined in an extended stay facility for experts to track vital information.

With care coordination technology, the patient or family member can track vital information and instantly send notes to a case manager or clinician. Likewise, clinicians can connect with the patient – send educational resources along with reminders to take meds, keep appointments, and follow through with important steps throughout the recovery journey. These interventions promote self-care, independence, and better outcomes that reduce avoidable readmissions and emergency room visits.

Strengthening the Post-Acute Care Connection

With the unfolding of health tracking apps, providers must consider the aging global population’s influence. By 2050, the number of people 65-plus is expected to triple to 1.5 billion.

“Clearly there is a disruption,” said Joseph Kvedar, MD, vice president of connected health at Partners Healthcare, during his presentation at the HIMSS18 Global Conference & Exhibition's Digital & Personal Connected Health event. “With twice as many people over age 65, we need more resources no matter how well we’re doing.” Dr. Kvedar explored the critical steps needed to help us lead healthier, more active lives as we get older, and the connected health solutions needed to accommodate the aging population.

Expanding the traditional care plan to post-acute care continuity extends beyond achieving short-term outcomes to realizing long-term gains through a healthful lifestyle. Providers can play a significant role in motivating self-care choices such as nutrition, exercise, and social connections – customized to each patient’s lifestyle. Not every patient approaches self-care in the same way. Interactive technology is designed to accommodate patients’ varying attitudes and needs. And patient engagement is essential to sustainable outcomes.

Promoting Patient Engagement

Patient engagement starts with giving patients the tools they need to understand what makes them sick, how to stay healthy and what to do if their conditions worsen. It means empowering patients to participate in their care by asking questions, knowing their medications and medical history, bringing friends or relatives to appointments for support and learning about care that may be unnecessary. Engagement varies depending on a patient’s lifestyle, skills, and interests.

Here are 10 tips to promote patient engagement:

  1. Communicate via email and text to send appointment and medication reminders. 
  2. Make your website smartphone-compatible.
  3. Recommend mHealth apps to encourage self-monitoring.
  4. Use ePrescribe and online prescription renewal requests. 
  5. Ensure easy access to educational resources – online information about medications, types of therapy and other topics.
  6. Schedule appointments online. Many patients prefer it, and it’s more efficient.
  7. Allow patients to enter their own data via online portals. Physicians can easily track progress and modify treatment plans between visits if necessary.
  8. Ensure online access to patient medical records – a top patient request. On-demand access to lab results and appointment information expedites care management.
  9. Use social media. Launch initiatives encouraging patients – particularly those with chronic pain – to share their stories. Share online videos with patients as an educational tool.
  10. Make managing healthcare fun with mHealth apps that gamify the experience. Patients are more likely to log their workouts and meals when they get points for doing it.

We’re experiencing an unprecedented time in healthcare innovation. The advent of high-tech options to engage patients and the entire care team is transforming the traditional discharge plan into a post-acute care continuity plan – a core component of value-based initiatives.

Original article
HIMSS Clinical Informatics Insights

Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.

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