As of last year, the era of health care reform has fully taken effect. The many changes brought uncertainty to health care providers, as well as patients.
The changes in quality measures and reimbursement were meant to bring about high quality care at the lowest price.
As we read, listen, and participate in meetings, many terms and buzz words are being batted around to describe the changing landscape of health care such as... "continuum of care... collaborative care... transition of care... and value-based care." But to most health care providers and patients, the bottom line still remains how to provide time efficient, quality care that protects patients from harm and decreases provider liability.
The challenge for most health care providers is to identify and implement systems/processes to optimize patient care transitions and avert costly new penalties for Medicare readmissions. This can be accomplished through a team approach. A patient's post-discharge team includes hospitals, hospitalists, primary care physicians, nursing and rehab centers, community health workers, family members – and last but not least, the patients themselves. This "team" must be on the "same page" to ensure compliance with some very important processes:
• Comprehensive written discharge instructions
• Complete medication list, instructions, and side effects
• Scheduled follow-up appointments
• Health care provider contact information for questions
Recent statistics show that 71 percent of hospitals are experiencing reduced Medicare payments because of readmissions. The lost payments nationwide amounted to $15 billion and three-quarters of readmissions are preventable.
When health care providers start to look for ways to decrease readmissions and thus improve patient outcomes and quality, TeamHealth, one of the nation's largest providers of hospital based clinical outsourcing, offers five core concepts to reduce readmissions. The core concepts include:
• Recognition - Recognize potential post-discharge issues that may cause readmission.
• Communication - Active communication between team members, patients, and families.
• Intervention - Continuously manage patient expectations. Every contact with the patient should include post-hospital care management.
• Education - Empower the patient/family to actively participate in discharge planning.
• Reconciliation – Continuous EHR medication reconciliation at admission, discharge, and throughout the hospitalization.
Risk Strategies
To discourage readmissions, health care providers could implement the following:
1. The discharge summary should be complete and transmitted to the outpatient health care providers as soon as the patient is discharged. Like the admission note, the discharge summary is an equally important document.
2. Tell the patient whom to call for questions or problems. Establish an office staff member to field calls from newly discharged patients.
3. Office staff should be aware of patient discharges. Systems to follow-up with the discharged patient are valuable in preventing readmission.
4. Patients should never be discharged without adequate instruction and education. All inpatient health care providers should share in this responsibility.
5. Many medication errors occur at the transition points. Computerized Physician Order Entry (CPOE) systems are good at reducing errors in prescribing but they cannot detect an error if the provider does not prescribe a medication that the patient was taking at home. Electronic medication reconciliation may reduce these unintended discrepancies.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.