Changes in the way Medicare pays health care providers have created a strong inducement for hospitals and health systems to get patients involved in their own care.
But, unless patients make a real effort to adhere to care plans and learn to self-manage their conditions after discharge, there’s little chance that providers and accountable care organizations (ACOs) will cut costs enough to succeed under value-based reimbursement.
Hospitals can only do so much to improve the patient experience. Patients have to meet them half way. Fortunately, technological solutions exist to bridge the connection between patient and provider, even after discharge. Here are 10 ways integrated technology supports patient engagement post discharge.
1. Continue patient education. Interactive patient systems (IPS) give caregivers the ability to prescribe health education through personalized workflows. Providers can assign video content during a hospital stay on everything from how to prepare for discharge to understanding medications to managing self-care for chronic conditions such as heart failure and asthma.
However, evidence suggests patients and families are only able to consume limited information while in the hospital. The IPS makes cloud-based health education and management tools available to patients and families post-discharge through any web-enabled device. This makes it easier for them to access and consume the information at their own pace.
2. Reinforce care plan compliance. Discharge instructions are complex and often difficult to understand. It’s no wonder that a third of patients can’t explain their medications, and half don’t know their diagnoses when they leave the hospital. IPS solutions facilitate better transitions of care and lower the risk of readmission by putting personalized care plans and interactive self-care resources at patients’ fingertips.
Step-by-step lessons on conditions, medications and treatments help patients and families learn at their own pace, and interactive self-care resources promote active health management. An IPS prepares patients for the journey home or to a post-acute-care facility and increases the likelihood of optimal outcomes by reinforcing routines and promoting long-term health and wellness post discharge.
3. Identify intervention opportunities with surveys. Health care organizations can administer patient engagement surveys through an IPS. These questionnaires gauge an individual patient’s motivation and capacity to care for themselves, both during and after their hospitalization.
Post-acute providers receive alerts on the need for early intervention for patients scoring low on these measures before discharge. Similarly, results that indicate a patient is not complying with their care plan at home will trigger a critical alert giving care managers an opportunity to perform outreach.
4. Measure patient activation. While it may not be possible to engage every patient, it is possible to measure the extent to which a person can be activated to manage their own care. The Person Engagement Index™, an 18-question survey used in conjunction with one IPS solution, helps perform this measurement. This validated survey assesses a patient’s capacity to be engaged in four domains, including their overall ability to engage, how proactive they are, their ability to use technology and their psychosocial support. The overall score and scores from each domain are supplied to clinicians.
5. Personalize care plans. Drawing upon this data and clinical assessments, the provider and the patient can jointly create a post-discharge care plan that reflects the person’s specific needs, preferences and resources. With continuing support from the hospital, the patient is more likely to understand and adhere to their care plan, increasing the likelihood of an optimal outcome.
6. Leverage cloud-based tools. Mobile apps for smartphones and tablets extend the reach of care beyond the hospital walls — allowing providers to deliver dynamic, personalized care in real time. Whether through a patient portal integration or as a standalone app, patients are able to tap into cloud-based health education and management tools like digital checklists and health journals and content on procedures, conditions and prescribed medications from any web-enabled device. Care team members can also push automated reminders and care tips to patients through these apps, promoting better care plan compliance.
7. Track post-discharge compliance and progress. Mobile apps make it easier for providers to monitor compliance, comprehension and trends and adapt care plans accordingly. The EHR automatically documents completed assignments, communication exchanges and patient-reported milestones. This real-time insight helps clinical teams track progress, prioritize outreach and determine whether to assign additional education, goals and challenges.
8. Make hospital data patient-accessible. The mobile app of one IPS company gives patients digital access to all medication information and patient education prescribed during their hospital stay. Patients can refresh themselves on what happened during their hospitalization and share the data with their ambulatory care and post-acute-care providers. This can be especially helpful when providers are not able to exchange clinical information easily. It may become critical in post-discharge medication reconciliations designed to avoid adverse drug interactions.
9. Conduct a telehealth follow up. Many IPS solutions also integrate with telehealth software to support virtual visits with a patient in the convenience of his or her home. Supplemented by the educational content and the engagement survey results in the IPS, the physician can interact with the patient in real time to fine-tune their care plan and continue to encourage them to take an active role in self-care management.
10. Overcome low health literacy. Many patients struggle to follow discharge instructions correctly or to take medication as prescribed because of low health literacy. A robust IPS solution tailors to individual diagnoses and adjusts to health literacy levels.
Step-by-step curriculum, geared to a patient’s level of understanding, guides them through self-paced multimedia learning modules that educate, inform and inspire successful at-home care management. Periodic interactive assessments reinforce retention while gauging comprehension and documenting results in the EHR.
Providers can access the results of these activities and determine whether there’s a need for personal outreach.
About the author
Linda F. Robinson, MSN, BSN, RN, is a Solutions Specialist at GetWellNetwork, the Precision Engagement™ health care company with the only cross-continuum platform that performs across every care setting. Linda has 31 years of nursing experience focused on interactive patient care, most recently serving as St. Elizabeth Healthcare’s Manager of Innovation and Process Transformation.