How do we efficiently move patients and relevant clinical information through the care continuum and ultimately reduce unnecessary readmissions?
Multiple workflows, a lack of transparency, and poor patient engagement combined with limited EMRs in post-acute facilities all contribute to the problem. Today, our hospitals are being forced to move from a fee-for-service to a value-based system, and until we find the right solution to these challenges, patients lose.
The financial viability of our health-care institutions depends on us figuring out a solution that will result in better care and a better patient experience. Readmission penalties add up fast. In 2015, 2,592 hospitals were penalized a total of $420 million. I believe care planning and communication are at the heart of a multi-layered solution that facilitates smooth care transitions for patients and their families.
So what stands in the way? In the acute care world, administrators and front-line providers have identified a number of potential solutions, but the real questions to ask are:
- What are the barriers?
- What solutions will give us traction?
Today, most hospitals have EMRs in the inpatient setting but these systems are much less prevalent in the outpatient setting. Meanwhile, post-acute providers are trying to figure out how to pay for the solution that really makes sense. Even if the post-acute provider has an EMR, very few of EMRs talk to each other.
Hospitals have separate and multiple workflows that often reside in silos. The lack of insight and transparency into a patient’s care path makes it difficult to get data back and forth to one another— even if you have willingness and an IT platform that allows it.
A lack of patient engagement also stands in the way of coordinating patient transitions. Don’t assume that we have willing and engaged patients and families that want us to coordinate care.
Many possible solutions
The challenge of care coordination has many possible solutions. The first level of response should involve a needs assessment of the patient prior to discharge. Not just specific clinical needs, but social, family support and transportation needs. These non-clinical factors that are just a few of the factors that increase the probability for readmission. Hospitals that match patients with the facilities that best meet clinical and socioeconomic needs will likely have fewer readmissions.
Risk stratification should also play a part. Certainly, hospitals can’t afford to follow everyone. So, identifying patients who need intervention is key.
Lastly, linking systems and people together will require technology. Any care coordination solution will need to integrate with the various IT systems, health apps, mobile devices and enable multi-directional communication for everyone who bears some responsibility for the patient. By having everyone on the care team connected, patients are more likely to flourish and avoid readmission entirely.
Though nothing replaces the “high-touch” factor of people in health care, leveraging technology can go a long way toward improving patient outcomes. Robust health-care IT can provide risk stratification, patient communication and monitoring and alerts when patients miss important steps in their care plan.
Learn more about how using technology can increase patient handoff reliability in our white paper.