At the National Readmission Prevention Collaborative Summit a few weeks ago, I spoke about the challenges health-care organizations face today in facilitating effective care coordination and how addressing those challenges can impact the patient experience.
Namely, when discharge planning and care coordination are successful, hospitals and health systems are better equipped to navigate patients through the care continuum, reducing readmissions and ultimately improving patient outcomes. However, realizing effective care coordination can be challenging as there are several barriers organizations must first overcome.
Limited use of EHRs. Thanks to Meaningful Use incentives and other regulations, most hospitals are now using electronic health records (EHRs). In fact, as of last year 93% of hospitals were using EHRs in some capacity. Although EHRs are contributing to better, more efficient information sharing within and between inpatient settings, their reach typically does not extend to outpatient locations, which can present roadblocks for keeping patients “in sight” during post-acute care.
Multiple workflows. Having worked in hospitals for many years, I’m very familiar with the silos that exist, each with their own, separate workflows. Unfortunately, these silos are also present outside the hospital and further impede necessary dialogues between providers to effectively coordinate care throughout the continuum.
Pay-to-play models. Due to the costly investment involved in implementing different software types, many providers are unable to participate in pay-to-play networks. Post-acute providers in outpatient settings in particular often aren’t able to serve as network partners, requiring discharge planners to continue using traditional, time-consuming processes to identify possible post-acute placements.
Lack of transparency. Even in the digital age, exchanging data within and between health-care organizations is challenging. With multiple technology solutions and workflow processes in place both internally and among different health-care organizations, compatibility and interoperability issues still exist—and likely will for the foreseeable future.
Poor patient engagement. Keeping a patient engaged in his or her care is an essential component of care coordination, as patient and family engagement leads to improved care plan compliance and better patient outcomes. However, engaging patients is not always an easy task—especially when some patients are not willing to be actively involved in their own care plans—presenting a challenge when trying to coordinate post-acute care.
These barriers, as well as other contributing factors, complicate care coordination efforts and require health-care organizations to take a multifaceted approach, applying not only evidence-based practices and efficient processes, but also enabling technology to successfully coordinate care across the continuum.
Using technology, providers can assess patients’ risk for readmission based on diagnoses, outline post-discharge milestones for patients and intervene if milestones aren’t met to help prevent readmission. In addition, technology can facilitate care transitions to assure patients move smoothly from setting to setting, getting the post-acute care they need to adhere to their treatment plans. Technology also helps patients and providers stay connected with each other, allowing providers to continue exchanging information across the care continuum while keeping the patient engaged and at the center of care.
How is your organization leveraging different technologies to improve the patient experience, reduce length of stay and/or readmissions? What solutions have you found to be most effective?