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.
Foster transparency. It used to be that once a patient was discharged, the hospital stopped communicating with the individual, trusting the patient’s care to the next setting. However, with the additions of bundled care payments, hospitals and health systems are now held accountable for patient readmissions up to 90 days after discharge, so it’s important to find ways to keep track of individuals over time. For a patient who enters a post-acute facility, this may mean having regular contact with the facility to check on the patient’s status. For those individuals who are discharged home, care coordination technology can help providers manage and track patient information, including blood pressure, pulse oximetry and other vital signs. Through these various technologies, the hospital can quickly determine which patients are following their care plans and which might need interventions to prevent hospital readmissions. Case managers can then shift their focus and attention on those patients who may require more assistance.
Engage patients. As mentioned above, not only must the hospital be accountable for care coordination after discharge, the patient bears a responsibility as well. While some patients are diligent about adhering to their care plans, others may need a little push. Care coordination technology that collects patient vitals and then communicates them to the hospital can help ensure patients stay on the right track. For example, a hospital can send a patient home with a Bluetooth-enabled scale, blood pressure cuff and pulse oximetry monitor. Every time the patient uses one of these tools, the readings are automatically sent to the hospital for review. If the patient skips a reading, or if the reading reveals a concerning trend, the hospital can reach out. For those patients who refuse to use the technology, the hospital can leverage a care coordination app that includes a patient's family members and primary care physician. For example, when the patient does not use the scale, the hospital can contact the patient’s family or doctor and ask them to get involved in encouraging the patient to participate in his or her care. This oftentimes improves patient engagement which further results in better outcomes.
Having a well-tuned care coordination process won’t happen overnight; however, organizations that leverage care coordination technology to communicate with their network, foster transparency and engage patients can take a significant step in the right direction.
To hear more about care coordination and its growing importance in the healthcare industry, see some of Ensocare’s recently published articles.