Ensocare Thought Leadership

Ensocare frequently contributes content to and shares thought leadership in well-known trade journals and magazines. We would welcome the opportunity to share our expertise in the areas of care coordination, care transitions, readmissions and reimbursement, meaningful use or other topics relating to improving healthcare and the patient experience. To schedule an interview with any of our healthcare executives, please contact us. Media inquiries may be directed to: Kathy Sullivan, Vice President of Marketing (Ph. 402-758-2605).

Ensocare in Recent Publications

Leveraging Technology to Overcome Care Coordination Hurdles

Posted by Luis Castillo on Dec 13, 2016 2:07:40 PM

December 13, 2016 - Becker's Health IT & CIO Review

By Luis Castillo, President and CEO of Ensocare

Hospitals and health systems are starting to recognize the value in coordinating care after patient discharge. The more these entities are able to communicate and collaborate with post-acute providers, patients, families and community support services, the greater the likelihood of reduced readmission rates and positive long-term patient outcomes.

Read the rest of the article in Becker's Health IT & CIO Review here.

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Topics: Care Coordination, Healthcare IT

Optimizing Care Transitions: A Key Strategy for Reducing Readmissions

Posted by Mary Kay Thalken, RN, MBA on Dec 13, 2016 1:33:08 PM

December 8, 2016 - Health System Management

By Mary Kay Thalken, Chief Clinical Officer

The following sections offer a roadmap of how to re-envision care transitions to increase their reliability and mitigate risk.

Last year, the Centers for Medicare & Medicaid Services (CMS) withheld a collective $420 million in reimbursements from half of the nation’s hospitals due to readmission penalties. As CMS continues adding condition- and procedure-specific regulations through its Hospital Readmissions Reduction Program (HRRP), associated penalties will also increase, placing even more financial risk onto providers. If organizations don’t get a handle on how to limit readmissions, the financial impact alone will be substantial — not to mention how patients will perceive the quality of care organizations deliver.

Improving care transitions to prevent readmissions

It is estimated that as many as 75% of Medicare readmissions are avoidable, causing a great deal of unnecessary spending. In fact, according to the National Learning Consortium, approximately $44 billion in wasteful healthcare spending is attributable to unplanned hospital readmissions.

A significant root cause is poor care transitions between hospitals and post-acute settings, such as skilled nursing facilities, rehabilitation programs and home health care. Traditionally, the hospital discharge process has been fraught with communication breakdowns and poor information exchange, which cannot only yield less-than-ideal outcomes but can increase the likelihood a patient will return to the hospital.

However, when organizations take a more systematic approach, they are able to improve workflow, limit communication lapses and address other challenges. Such an approach includes a few essential components.

Target At-Risk Patients

As early as admission, hospitals can begin identifying individuals at risk for readmission based on clinical, social and financial factors, including the patient’s condition, health history, family support and more. A 75-year-old woman undergoing total hip replacement with a strong family support system who historically follows her care plan will tend to have a lower readmission risk than someone with no home support and a history of poor care plan adherence.

By identifying concerning factors early, hospitals can proactively address them when coordinating a post-acute transition. Perhaps the hospital will make additional follow-up calls to the high-risk patient, arrange for a nursing service to periodically visit the individual or use mobile applications to stay in contact with the patient and family over a period of time. By proactively stratifying and mitigating risk, organizations can effectively allocate resources and focus their attention on patients who need it most.

Ensure Appropriate Post-Acute Placement

In some hospitals, patients and their families aren’t given much time, information or guidance to select a post-acute provider when one is necessary. However, this placement could potentially mean the difference between a positive outcome and an unplanned trip to the hospital. Finding the right facility that not only accepts the patient but also meets all of his or her clinical and psychosocial requirements is key.

For instance, if a patient recovering from a stroke requires physical, occupational and speech therapies multiple times per week, the post-acute care facility must be able to meet all of these needs. Otherwise, the patient may have to be transferred to another location or return to the hospital, potentially causing upheaval for the patient and financial consequences for the hospital.

Manually searching for appropriate facilities is labor-intensive, time consuming and may still not yield the best fit. Rather than calling individual locations, hospitals that use care coordination technology can generate a customized request based on the patient’s clinical and psychosocial needs and share that request with surrounding post-acute providers simultaneously, obtaining responses in minutes rather than hours—or even days. Hospitals can then share this well-vetted list with the patient and his or her family, helping them make a more informed choice surrounding the next stage of care. Leveraging technology in this manner can expedite the post-acute placement process while ensuring the patient finds the most suitable match.

Hospitals can also use care coordination technology when trying to identify additional services for patients who are ready to be discharged home. Consider the person who lacks transportation and yet is expected to pick up his or her prescriptions, attend appointments and purchase groceries. Without addressing the underlying need for transportation, the hospital increases the risk the patient will not follow his or her care plan and thus elevates the likelihood of readmission. Hospitals can use technology to match patients with necessary services—transportation, housekeeping and meal delivery—thus better preparing individuals to navigate the post-discharge environment.

Facilitate Robust Information Exchange

The traditional process for sharing information between hospitals and post-acute care organizations is sending all or a large portion of the patient’s medical record to the receiving facility. Although this process has become more streamlined since hospitals started using electronic health records (EHR), most organizations still share more information than is needed, and sometimes it does not arrive in a timely fashion.

However, using automated care coordination tools, hospitals can share the most relevant information directly from the EHR, ensuring receiving clinicians have all the information they need to support care quality and continuity—and the data arrives in an easily digestible form. By receiving this information prior to the patient’s arrival, post-acute care providers are able to prepare prescription and therapy orders in advance to prevent any delays or gaps in care.

Stay in Contact with Patients and Families

Historically, once a patient was discharged, the hospital would lose track of the individual, moving on to new patients and new priorities. However, now that hospitals are responsible for patient outcomes for 90 days post discharge, it is in their best interest to identify ways to stay in touch. Hospitals can leverage care coordination technology to virtually follow patients in post-acute settings. Such solutions allow the organization to continue stratifying patients and adjusting their readmission risk as they progress through their care plans. For patients who transition home, hospitals can use solutions that rely on mobile apps and electronic messaging to ensure patients adhere to their care plans. For instance, if patients miss appointments, fail to meet milestones or neglect to fill prescriptions, the technology will notify the hospital and other care team members, allowing them to intervene accordingly.

Technology Plays an Essential Role

As can be seen in the previous strategies, a strong technology infrastructure can facilitate safer and more consistent care transitions. By using automated solutions, organizations can improve both the efficiency and reliability of these high-risk times. According to CMS, “Gaps and duplication in service delivery can be reduced or eliminated through the use of technologies,” and the agency encourages organizations to collaborate using these kinds of solutions.

In a time when hospitals are facing ever-increasing financial risk and responsibilities, harnessing care coordination technology can enhance the discharge process, ultimately reducing the chances for readmission.

Read the full article here.

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Topics: Care Coordination

Three ways technology can lead to bundled payment success

Posted by Luis Castillo on Nov 8, 2016 12:33:51 PM

November 4, 2016 - Managed Healthcare Executive

By Luis Castillo, President and CEO of Ensocare

As organizations embrace value-based care, they are beginning to appreciate the importance of robust care coordination. The more providers collaborate and communicate, the more likely patients are to receive appropriate, non-duplicative and timely interventions, which can mitigate risk, reduce costs and yield better patient outcomes.

Coordinating care is especially critical now that hospitals are required to comply with the Centers for Medicare & Medicaid Services (CMS) bundled payment initiatives—specifically, the Comprehensive Care for Joint Replacement (CJR) model and the cardiac care model. These programs point to the need for a broad healthcare team that should include the hospital, the patient and family and any post-acute providers, with the hospital at the center, assuming the majority of risk for the quality and cost of care. Since these initiatives represent the first of many similar risk-based models, it is clear organizations no longer have a choice as to whether to coordinate care across settings—it is becoming a necessity for long-term viability.

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Topics: Care Coordination, Healthcare Reform, Healthcare IT

Rethinking Discharge Communication

Posted by Mary Kay Thalken, RN, MBA on Nov 4, 2016 11:31:17 AM

October 31, 2016 - Advance Healthcare Network for Nurses

Six Ways Nurses Create a Smoother Transition to the Next Phase of Care

By Mary Kay Thalken, RN, MBA, Chief Clinical Officer of Ensocare

Communication errors are the number one cause of adverse events in hospitals, according to the Joint Commission, and times of transition-including patient handoffs, transfers and discharges-are especially risky. In the ramp up to patient discharge, for example, nurses, case workers and care managers are busy with a plethora of diverse tasks that pull them in many different directions. This creates an environment where communication exchanges are, at best, fragmented. It also sets the stage for potential communication breakdowns between hospitals and post-discharge providers, which can, in turn, lead to lapses in care or duplicative care, or medication errors.

Contemplating what to do after discharge from the hospital can be daunting for both patients and families. If leaving the hospital doesn't equate to going home, decisions surrounding post-acute facilities for continuing care must often be made quickly, and without a great deal of supporting information. This can cause both the patient, and the receiving facility, to be ill-prepared for what comes next.

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Topics: Care Coordination, Patient Discharge

Better Care Transitions Yield Better Outcomes

Posted by Mary Kay Thalken, RN, MBA on Oct 31, 2016 11:51:13 AM

October 31, 2016 - HIT Leaders & News

By Mary Kay Thalken, RN, MBA, Chief Clinical Officer of Ensocare

Healthcare organizations have long struggled with care transitions, especially when moving complex patients who require multifaceted care from acute settings to a post-acute environment. These transitions are often fraught with communication breakdowns, poor information exchange and slow responses to changing patient conditions. As a result, patients frequently don’t receive the care they need, or that care is delayed, causing them to end up back in the hospital. According to the Centers for Medicare & Medicaid Services (CMS), nearly 20 percent of Medicare patients discharged from a hospital are readmitted within 30 days, at a cost of more than $26 billion every year. Not only do inadequate transitions have ramifications from a cost perspective, they also negatively affect patient satisfaction and the overall patient experience.

Left unchecked, the issue of poor care transitions will continue to decline as the population ages. In fact, it is estimated that by 2030, one in five U.S. residents will be 65 years or older, and since older patients are more apt to visit the hospital and require post-acute care after discharge, it is becoming even more critical for these care transitions to be smooth and seamless.  

Insufficient communication is the main reason why care transitions break down. When organizations do not have processes and systems in place to facilitate consistent information exchange, important data can be lost, increasing the risk for potential issues that could occur. Additionally, it is estimated that 80 percent of serious medical errors are attributable to miscommunication during hand-offs, and these communication deficits often lead to poor, if not detrimental outcomes.

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Topics: Care Coordination, Patient Discharge

Reimagining Discharge To Elevate The Patient Experience

Posted by Jill Reeves, MHA on Aug 22, 2016 12:25:05 PM

August 22, 2016 - Health IT Outcomes

By Kyle Salem, Managing Director at CQuence Health Group and Ensocare Member of the Board

With the proliferation of high-deductible health plans, patients have a greater financial stake in their care than ever before — in some cases paying thousands of dollars for a single care episode. Likewise, hospitals are taking on more financial risk for patients beyond the hospital stay. Programs like the Comprehensive Care for Joint Replacement Model (CJR) and the proposed rule for cardiac bundled payments put hospitals at financial risk for managing the quality and efficiency of care delivered throughout the care episode and during the 90-day period after the patient leaves the hospital.

The increased financial responsibility on the part of all stakeholders, coupled with a general growth in healthcare consumerism, is prompting hospitals and health systems to take a closer look at the patient experience.

One especially vulnerable area relates to care transitions. When patients move from one care setting to another, the experience is often complicated and fragmented. Insufficient communication plus a rushed dynamic results in inefficiencies, gaps in care, and missed opportunities to optimize quality and be compassionate. The entire process can be stressful for patients, not to mention expensive and clinically risky.

Care transitions do not have to be this way. By rethinking the way patients move from one stage of care to another or from one physical care location to another, hospitals and health systems can ensure they are more proactive and patient-centered. The following are a few key communication touchpoints and simple process best practices for reimagining patient transitions.

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Topics: Care Coordination, Patient Discharge

Podcast | Coordinated Care Continues to Evolve

Posted by Jill Reeves, MHA on Jul 21, 2016 10:46:34 AM

intrepidNOW Podcast

Kyle Salem, Chief of Staff at CQuence Health Group and member of the board of directors for Ensocare recently discussed how care coordination continues to evolve with Editor-in-Chief Joe Lavelle from intrepidNOW. 

Kyle shared key pain points many hospitals have when it comes to care coordination and how improved care coordination can impact a hospital's bottom line.

Click here to listen to the podcast.

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Topics: Care Coordination, Care Transitions

Elevating Communication During Care Transitions

Posted by Jill Reeves, MHA on Jun 20, 2016 2:32:55 PM

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 Jill Reeves, MHA on Jun 14, 2016 3:20:00 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: Post-acute Care, Care Coordination

Using Technology-enabled Care Coordination to Boost Quality Outcomes

Posted by Jill Reeves, MHA on Jun 6, 2016 11:00:00 AM

June 6, 2016 - Becker's Hospital Review

"Improve quality, optimize efficiency and reduce costs" is a mantra that healthcare organizations all over the country repeat as they aim to navigate new payment models on leaner budgets. To turn these goals into reality, forward-thinking hospitals and health systems are bolstering efforts to communicate with post-acute facilities, physician practices and other care locations.

These organizations realize that without strong care coordination between settings, there is greater risk for errors and unfavorable outcomes, in addition to potential increases in length of stay (LOS) or unnecessary readmissions. In the same vein, the Centers for Medicare and Medicaid Services (CMS) has introduced new reimbursement models, such as the Comprehensive Care for Joint Replacement (CJR) model, where effective communication and care coordination between hospitals and other settings aren't just a good idea, they're required to reduce risks and promote quality outcomes.

A key opportunity for elevating cross-continuum communication is the hospital discharge and post-acute placement process. Historically, the process of transitioning patients from one care setting to another has proven fragmented and inadequate. As a means to achieve better outcomes and to mitigate financial risk, organizations are turning to technology to optimize workflows and ultimately improve care quality and satisfaction.

There are many ways that technology can be used to improve post-acute activities and nearly all bring laborious processes, clerical inefficiencies and potential gaps into which care can fall short to the forefront.

Read more.

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Topics: Post-acute Care, Healthcare Reform