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With risk migrating from payers to providers, hospitals and health systems are now accountablefor patient outcomes following discharge. Because factors like readmissions, increased length of stay, poor patient outcomes and dissatisfaction can negatively impact not only the patient experience but also the organization’s bottom line, healthcare leaders are seeking effective solutions for mitigating these threats.
In response, Directors of Case Management can use EMRs with embedded discharge planning functionality and strategically deploy several tactics to reduce care transition risks while improving the patient experience, as well as workflow efficiencies.
By using the patient’s diagnosis (DRG) and associated geometric mean length of stay (GMLOS), clinicians and staff can project a probable discharge schedule, the patient’s likely discharge disposition and recovery course, as well as probable outcomes, and begin preparing for the patient’s transition almost immediately after admission. Hospitals can then engage discharge planners earlier, allowing ample time to discuss the care transition plan and post-acute options (if needed) with the patient, his or her family, nursing staff and physicians.
Involving discharge planners earlier may necessitate a fundamental change in workflow sequence. Typically, discharge planning doesn’t commence until the physician issues orders shortly before the patient’s departure. However, starting the discharge planning process will ensure the care team collaborates with the patient and family to realize a smooth, efficient and satisfactory transition.
When hospitals empower discharge planners with automated discharge solutions embedded within their existing EMR, they are able to further optimize valuable human resources to yield better patient outcomes. Discharge planners can spend time interacting with the patient and family caregivers and providing valuable education and guidance versus spending time on clerical and administrative tasks.
An effective discharge process should align patients’ clinical and social needs with appropriate providers upfront to ensure optimal placement and support continuity of care. Not only can this promote better patient outcomes and reduce readmissions, it can also increase discharge efficiency, which can reduce length of stay.
Some organizations choose to hire additional staff to manually coordinate discharge. However the option exists through technology to distribute referral requests to an already vetted network of post-acute facilities. Because the referral request is technology-enabled, patient information can be sent with the touch of a button to multiple facilities instead of faxed page by page to various facilities individually.
The potential time savings and payoff for hospitals are significant. A hospital using the Ensocare discharge planning solution reported a double-digit percent reduction in length of stay because of the time savings experienced due to more efficient discharge management. The embedded solution is supported with a 24/7 fullystaffed customer call center that helps to drive participation and responses from post-acute facilities.
Sharing health information between settings is challenging, particularly for organizations using manual referral processes that require the discharge planner to transfer confidential, protected health information via phone or fax.
Nonetheless, it is critically important for post-acute facilities to know patients’ needs prior to their arrival in order to effectively plan – to write orders, fill prescriptions, and begin scheduling essential treatments or therapies. If a post-acute facility does not receive relevant clinical information before a patient arrives on site, gaps in care may arise and either hinder long-term patient outcomes or result in readmission.
Using enabling discharge and care coordination technology, a standard packet of relevant patient information can be extracted from the hospital’s electronic medical record and shared with a receiving facility as soon as the organization agrees to take the patient. The discharge management software solution can either directly populate the receiving organization’s EMR with the needed information — the ideal scenario — or be used to electronically fax the information before the patient arrives on site.
In addition to transferring information to post-acute facilities, automated discharge planning technology can be used to coordinate and transfer needed patient data to non-clinical community care providers, such as transportation companies that deliver patients to follow-up appointments.
Organizations using an EMR are already embracing these three tactics and beginning to realize improved patient outcomes, reduced readmissions and overall improvements in the patient experience.
Use of the Ensocare-powered discharge management solution embedded inside Cerner also supports adherence to CMS Meaningful Use requirements to use certified electronic health record technology to CEHRT) to: