"Improve quality, optimize efficiency and reduce costs" is a mantra that healthcare organizations all over the country repeat as they aim to navigate new payment models on leaner budgets. To turn these goals into reality, forward-thinking hospitals and health systems are bolstering efforts to communicate with post-acute facilities, physician practices and other care locations.
These organizations realize that without strong care coordination between settings, there is greater risk for errors and unfavorable outcomes, in addition to potential increases in length of stay (LOS) or unnecessary readmissions. In the same vein, the Centers for Medicare and Medicaid Services (CMS) has introduced new reimbursement models, such as the Comprehensive Care for Joint Replacement (CJR) model, where effective communication and care coordination between hospitals and other settings aren't just a good idea, they're required to reduce risks and promote quality outcomes.
A key opportunity for elevating cross-continuum communication is the hospital discharge and post-acute placement process. Historically, the process of transitioning patients from one care setting to another has proven fragmented and inadequate. As a means to achieve better outcomes and to mitigate financial risk, organizations are turning to technology to optimize workflows and ultimately improve care quality and satisfaction.
There are many ways that technology can be used to improve post-acute activities and nearly all bring laborious processes, clerical inefficiencies and potential gaps into which care can fall short to the forefront. Among these are:
1. Risk Stratification
At the start of discharge planning, robust care coordination and discharge solutions can stratify risks and identify patients who might have increased chances for readmission or care plan noncompliance. Based on this assessment, discharge can be automated in routine situations, such as when patients are at low risk because of their ages, conditions at time of discharge or having family members involved in the process. This frees staff to focus on higher-risk patients who might not fare as well following discharge due to their conditions or health histories, lack of family support or other social issues.
2. Appropriate Placement
For patients who transition to the post-acute setting, ensuring they are sent to the most appropriate facility is critical. Poor placement can not only limit a patient's care and recovery, it can result in a return visit to the hospital—which is inconvenient at best for patients and an avoidable waste of time and resources for the hospital. Through technology-enabled care coordination and discharge planning, hospitals and health systems can be certain patients are discharged to a post-acute facility capable of meeting their clinical and personal needs.
3. Seamless Clinical Document Transfer
Using automated solutions, hospitals are also able to electronically send the most relevant information about a patient's condition prior to patient arrival. This information sharing closes potential care gaps by proactively delivering orders for medication, therapies and treatment, further reducing chances for errors or other adverse events. It also enables post-acute clinicians to make more informed decisions about next steps for care and treatment.
In addition to enabling effective post-acute placement through risk stratification, proper placement and assuring appropriate clinical document transfer, automated solutions can also support those patients who are going home after discharge. For instance, some care coordination solutions are capable of managing non-clinical services for patients, ensuring they follow care plans after discharge by arranging services including housekeeping, meal services, laundry, and grocery shopping as well as transportation to and from appointments or to pick up prescriptions.
CMS's CJR model is just the first of many programs that will require hospitals and health systems to collaboratively coordinate care and communicate more effectively with post- acute settings. By leveraging technology, organizations can successfully participate in these programs, reaching their goals of improving quality, optimizing efficiency and reducing costs.
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