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

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

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

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

Three Strategies for Improving Care Coordination

Posted by Jill Reeves, MHA on 11/28/16 8:00 AM

As hospitals and health systems increasingly take responsibility for patient outcomes post discharge, they are realizing the need for better care coordination after patients leave the hospital. Although there are many ways to take care coordination to the next level, here are three actions that are especially critical.

Strengthen your network. Placing patients who require post-acute care with an appropriate facility is something every hospital must do; however, some accomplish this task more successfully than others. Transitions tend to go more smoothly when organizations have a vetted network of certified post-acute providers that they can recommend to patients. Using care coordination technology, hospitals with a robust network can quickly share information about a patient to multiple, qualified providers at the same time and hear back within minutes as to which facilities can accept the patient. This allows the hospital to present a current, pre-qualified list to the patient and family, enabling them make a more informed decision about the next care setting.

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Topics: Care Coordination, Care Coordination Software

The IMPACT Act: Legislating Care Coordination

Posted by Jill Reeves, MHA on 10/18/16 8:32 AM

There is no question that cross-continuum care coordination is a good thing—the more various healthcare entities work together to deliver appropriate and timely interventions, the better off patients will be. That said, care coordination has often been viewed as a nice to have rather than a critical mandate. However, that is changing as the federal government approves legislation that requires diverse healthcare organizations to cooperate.

One such mandate is the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. While predominately aimed at the post-acute community and their preparations for risk-based care, the legislation’s overarching goal is to enhance collaboration among all members of the care team.

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Topics: Care Coordination, Healthcare Reform, Care Coordination Software

Ushering in the Next Generation of Care Coordination

Posted by Kyle Salem, Ph.D. on 7/25/16 1:36 PM

The extent of a hospital’s reach is changing. As the industry shifts towards value-based care, hospitals and health systems must think beyond its walls and work to coordinate care across the continuum, so patients can smoothly transition to the next care setting—until they ultimately return to wellness.

Until now, care coordination has been an incredibly inefficient process. Although most hospitals are adept at managing care within their organizations, it becomes more difficult when looking past the hospital setting. The problem is hospitals don’t have consistent and reliable methods for communicating with post-acute facilities and monitoring patient care. This is especially troubling because hospitals are being asked to take on more financial responsibility for patient outcomes after patients are discharged. Programs like the Comprehensive Joint Replacement (CJR) initiative from the Centers for Medicare & Medicaid Services (CMS) now require hospitals to coordinate care, signaling CMS is comfortable making these organizations the center of gravity for patient outcomes.

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Topics: Care Coordination, Care Transitions

Elevating Communication During Care Transitions

Posted by Mary Kay Thalken, RN, MBA on 6/20/16 3:42 PM

I'd like to share an article by Dr. Mark Kestner at Community Regional Medical Center, an Ensocare hospital client.

June 20, 2016 - Health System Management

The Effects of Consistent, Reliable Care Transitions on Clinical Care and Financial Outcomes

Care transitions—especially those that involve moving a patient from the acute to the post-acute setting—are often fraught with poor communication and a lack of cross-continuum information-sharing, resulting in care lapses that can lead to medical errors, unnecessary hospital readmissions and other negative clinical and financial consequences. However, forward-thinking organizations are realizing the importance of improving these transitional periods in order to reduce risk, boost care quality and sustain positive patient outcomes and satisfaction, even after a patient leaves the hospital. 

Community Regional Medical Center (CRMC)—a locally owned, not-for-profit, public-benefit health system based in Fresno, Calif.—is one of these forward-thinking organizations that has committed to enhancing its care transitions. With four hospitals as well as several long-term and outpatient facilities, the organization is the region’s largest healthcare provider. It is home to the only Level 1 Trauma Center and comprehensive burn center between Los Angeles and Sacramento, and it is licensed for 900 beds, regularly seeing 95 to 100 percent occupancy. The center is constantly moving patients to other care settings, and because of its size and prominent role in the community, it recognizes how making care transitions more consistent and reliable could have far-reaching effects in terms of both clinical care and financial outcomes. 

Encouraging Standardization

One of the reasons why care transitions have been so risky is that communication during these times has historically been uneven and unpredictable. To address this issue, CRMC aimed to standardize its processes for discharge communication as much as possible.

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Topics: Care Coordination, Care Transitions

Realizing Optimal Outcomes in Care Transitions

Posted by Wayne Sensor on 6/14/16 3:24 PM

June 13, 2016 - Health System Management

Strategies that Aim to Facilitate Communication and Reliability
Moving between care settings can be a risky proposition for patients. When transitions are poor, patients may experience delays in treatment, a lapse in care continuity and the omission of vital therapies. Moreover, two-thirds of medical errors occur during care transitions—at admission, transfer or discharge and these breakdowns can have serious ramifications. On one side of the spectrum, a patient could have a slower recovery or a greater chance of acute care readmission; while on the other side, the individual may fail to return to expected functionality, resulting in long-term disability or even death.

Getting a Handle on the Problem
Despite the impact of sub-par care transitions, organizations continue to struggle to effectively move patients from one setting to another. For many, there is a lack of consistent processes, frequent delays and insufficient communication. To improve the efficiency and safety of these critical time periods, organizations should consider these strategies that aim to facilitate communication and enhance overall reliability.

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Topics: Care Coordination, Healthcare Technology Solutions

IMPACT Act Brings Post-Acute Care Transitions to the Forefront

Posted by Mary Kay Thalken, RN, MBA on 5/30/16 8:30 AM

Through the use of standardized quality measures and standardized data, the intent of the IMPACT Act, among other obligations, is to enable interoperability and access to longitudinal information for such providers to facilitate coordinated care, improved outcomes, and overall quality comparisons.

Quality Measure Domains:

  • Skin integrity and changes in skin integrity
  • Functional status, cognitive function, and changes in function and cognitive function
  • Medication reconciliation
  • Incidence of major falls
  • Transfer of health information and care preferences when an individual transitions
Click here for Resource Use and Other Measure Domains.

By the end of 2014, 97 percent of all U.S. hospitals had met the foundational requirement of Meaningful Use 1 by having installed certified electronic medical records (EMR) technology. This achievement marks an important first step in the Centers for Medicare & Medicaid Services’ (CMS’) wide-scale effort to construct the technology infrastructure needed to bring the first real change to healthcare in decades. This foundation is absolutely essential to support the relentless drive toward a fee-for-value system.

A system that once rewarded hospitals financially for doing more procedures, is now demanding that if these procedures be done, they are done well. This greater push toward value brings the challenge of how to standardize communication among disparate providers to ensure patients receive the continuity of care required to prove and achieve quality outcomes.

As a result, healthcare organizations today are scrambling to keep up with the many new government initiatives, measurement, reporting, subsequent penalties, and standardization required to compete in the changing environment. The foundational investment made in the EMR was just the beginning. The challenge now is to make that system, and the many disparate systems that are used throughout the care continuum, to somehow speak a mutually agreeable vocabulary.

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Topics: Post-acute Care, Care Coordination, Healthcare IT