Home Again, Home Again — The Last Step in Recovery

Posted by Jill Reeves, MHA on 6/15/17 8:00 AM

Read Part I of Helen's Journey
Read Part II of Helen's Journey

Helen's Journey: Part III


It’s an exciting day for Helen! After being in the hospital for surgery and spending time recovering in a post-acute facility, she is now ready to go home. Although thrilled with the prospect of returning to familiar comforts—especially sleeping in her own bed—she and her family are a little uneasy. What if she has trouble adjusting? What if there are questions or concerns? What if her condition worsens?

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Topics: Care Coordination, Patient Discharge

3 Tips to Make You a Better Leader

Posted by Susan O'Malley, M.D. on 5/22/17 7:32 AM

As a former emergency room physician, each time I stepped onto the ER floor, I was leading a different team. The patients, staff and challenges were different, but the fundamental leadership principles remained the same.

You don’t have to be the CEO of an organization or the manager of a department to be considered a leader. We’re all leaders, and how we conduct ourselves impacts the morale and productivity of those around us. No matter your role in the organization, you will face different situations, people and challenges. Leadership is subjective; results are not.

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Helen's Post-Acute Journey - Part II

Posted by Jill Reeves, MHA on 5/15/17 10:21 AM

The Next Step on the Journey to Recovery

It’s Helen’s first day at the post-acute facility. As you may recall, she was discharged from the hospital to further recover from surgery. She and her family are extremely grateful the hospital medical team and discharge planners were able to use an automated discharge process tool to efficiently match her with just the right post-acute provider. The new organization has both the physical and occupational therapy services she requires, as well as the nutritional counseling she needs.

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Topics: Post-acute Care, Care Coordination

Technology Lessons from ACMA

Posted by Mary Kay Thalken, RN, MBA on 5/5/17 3:53 PM

From my own experience, I know first-hand that tracking patients post-discharge is an incredible challenge given the sheer size and scope of the effort. Hospitals release hundreds of patients each day, and communicating with them can be challenging.  Many hospitals have begun to focus on those patients who are at greater risk for readmission, such as those with multiple co-morbidities, limited family support, or a history of non-compliance with treatment plans or medication.

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Topics: Healthcare IT, Healthcare Technology Solutions

Planning for Hospital Discharge

Posted by Jill Reeves, MHA on 4/4/17 3:54 PM

Part One of Helen's Post-Acute Journey

From the moment Helen was admitted to the hospital for surgery, her care team including her doctor, case manager, nurses, family members, and post-acute facility are working together behind the scenes to prepare for a smooth transition once it is time for her to leave. To support a successful recovery and reduce her chance of readmission after discharge, Helen’s care team employs a collaborative approach so she and her family know what to expect:

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Topics: Care Coordination

Caring for the Caregiver

Posted by Megan Johnson on 3/29/17 8:01 AM


Most of us who work in the healthcare field do so because we have a genuine desire to help others. We attend several years of schooling—with many more beyond that in continuing education—to learn and maintain the complex clinical skills required to care for our patients.

But no one trains us for off-the-job caregiving. You know the kind I’m talking about. In addition to your professional role, you also likely play the unofficial role of a caregiver to your spouse, children, an aging parent, family friend or neighbor. With this added responsibility comes a need to understand the emotional impacts of caregiving—both on and off the job.

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Monitoring Patients Post-Discharge: A Key Step in Reducing Readmissions

Posted by Jill Reeves, MHA on 3/13/17 1:56 PM

In the past, when hospitals discharged a patient to the next level of care—whether it was to a post-acute facility or directly home—they stopped monitoring the patient’s treatment, condition and outcomes—sending the individual to their next destination and moving on to the next patient in crisis.

 However, times have changed. Hospitals and health systems are now held accountable for readmissions up to 90 days after discharge, and need to keep a closer eye on patients after they leave the hospital, engaging with them to ensure care continuity and mitigate readmission risk. If they don’t, there could be severe financial consequences along with dissatisfied patients.

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Topics: Healthcare IT, Healthcare Technology Solutions

Cultivating Patient Engagement

Posted by Jill Reeves, MHA on 2/20/17 8:00 AM

It stands to reason that patients who engage in their care after hospital discharge are more likely to achieve favorable long-term health outcomes and prevent unnecessary hospital readmissions. Unfortunately, some patients are not as engaged as they could be. In fact, about half of medications are not taken as prescribed, and people often miss follow-up appointments, therapies or other treatments as ordered. Whether this is deliberate or due to a lack of understanding or resources, hospitals and healthcare providers must find ways to effectively and efficiently reach out to patients after they leave the hospital—especially those at risk of readmission—to encourage care plan adherence.

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Topics: Patient and Family Engagement

Hard-to-Discharge is Now History

Posted by Jill Reeves, MHA on 2/16/17 9:18 AM

Although the discharge process is comprised of many moving parts, swiftly and safely transitioning patients out of the hospital does not have to be hard. Using robust care coordination technology, hospitals can seamlessly discharge patients—even the ones that are typically more difficult to transition.

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Topics: Post-acute Care, Care Transitions

Fostering Transparency

Posted by Jill Reeves, MHA on 2/6/17 8:00 AM

In recent years, the need for better communication and access to information across care settings has been a “hot button” topic in healthcare. In particular, being able to “follow” a patient after hospital discharge has become paramount due to health systems’ growing care coordination responsibilities and accountability for readmissions.

Although electronic health records (EHRs) and patient portals have helped to some degree, many hospitals are finding they need more visibility and reach into the post-acute and home environments to keep patients in sight once they leave the hospital. This is where care coordination solutions can make a significant difference:  

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Topics: Care Coordination