Hard-to-Discharge is Now History

Posted by Jill Reeves, MHA on 2/16/17 9:18 AM

Although the discharge process is comprised of many moving parts, swiftly and safely transitioning patients out of the hospital does not have to be hard. Using robust care coordination technology, hospitals can seamlessly discharge patients—even the ones that are typically more difficult to transition.

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Topics: Post-acute Care, Care Transitions

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

Using Technology and Proactive Communication to Help Prevent Avoidable Readmissions

Posted by Wayne Sensor on 4/14/16 9:00 AM

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.  

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Topics: Care Transitions, Healthcare Technology Solutions, Reducing Readmissions

Key Readmission Reduction Strategies

Posted by Wayne Sensor on 4/12/16 2:53 PM

Currently, hospitals are engaging in several initiatives to limit readmissions.

For instance, some organizations are pursuing mergers and acquisitions with the goal of keeping care under one umbrella throughout the continuum. The thought is that by strategically acquiring post-acute providers, hospitals can keep patients “in sight” during post-acute care. Unfortunately, this approach is costly and does not directly mitigate the drivers of readmissions.

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Topics: Care Coordination, Care Transitions, Reducing Readmissions

Using Technology to Meet CMS Discharge Planning Requirements

Posted by Wayne Sensor on 4/12/16 12:26 PM

On October 29, 2015, CMS proposed a new set of discharge planning requirements that HealthLeadersMedia_article.jpghospitals and other care providers must meet to receive Medicare and Medicaid reimbursement. According to CMS, the proposed rules are meant to modernize the discharge function and help organizations improve care quality and avoid adverse events, such as unnecessary complications or hospital readmissions. The comment period for these proposed standards ended in January, and organizations await the final rules. Although no one knows exactly when the rules will release or what form they will take, there is consensus that the final regulations will be similar to those proposed, and organizations will be required to comply with them sooner rather than later.

Overall, the new CMS regulations strongly emphasize the importance of taking the patient’s clinical needs, care goals, and psychosocial preferences into account when planning for discharge. The main idea is that if organizations place the patient at the center of the planning process, they will improve patient health outcomes, enhance satisfaction, reduce care costs, and limit the likelihood of medical errors.

Read my full article published by Health IT Outcomes to learn how technology can help providers meet the new CMS standards.

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Topics: Care Coordination, Care Transitions, Reducing Readmissions

Empowering Patients to Engage and Follow Care Plans Post Discharge

Posted by Mary Kay Thalken, RN, MBA on 4/11/16 9:00 AM

As health care has evolved, the patient’s role in following his or her care plan after discharge has increased, and hospitals need to find ways to help patients help themselves. According to The Advisory Board Company’s Annual Health Care CEO Survey, 45 percent of hospital executives are interested in identifying patient engagement strategies. It’s no secret that engaging patients in their care is essential to care quality, increasing patient satisfaction and, ultimately, achieving positiveoutcomes. However, when the patient leaves the hospital it can be a challenge to sustain patient engagement, especially when it comes to maintaining communication and overseeing care continuity.

Though patient and family engagement can be tough once a patient is out of sight, there are ways to facilitate communication, continue oversight and ensure patients follow established care plans.

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Topics: Care Transitions, Patient and Family Engagement, Patient Outcomes

Leveraging Technology to Reduce Hospitals’ Growing Financial Risk

Posted by Mary Kay Thalken, RN, MBA on 3/31/16 9:27 AM

The reality of reform is harsh. In 2015, 2,592 hospitals were penalized to the tune of $420 million dollars for patient readmissions.

To attack the readmission challenges that hospitals face, you must first understand and solve the discharge challenges. The point at which the patient transitions from the hospital to the next level of care is a mission critical point.

The recently proposed Centers for Medicare & Medicaid Services (CMS) discharge planning regulations present an opportunity for hospitals and other health-care providers to improve the discharge process. With the proposed regulations, hospitals are faced with the need to:

  • Provide better communication and coordination with disparate providers and facilities
  • Accurately determine the level of readmission risk of a patient as well as specific areas of concern
  • Move patients as quickly as clinically appropriate to a lower level of care
  • Provide both clinical and non-clinical services to keep the patient well
  • Maintain communication and patient status at the patient’s care facility, home or other service location
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Topics: Care Transitions, Medicare Readmission Penalties, Healthcare Technology Solutions

3 Ways Hospitals Can Navigate “Act One” of CJR Payment Rule

Posted by Mike Cassling, Chairman and CEO of CQuence Health Group on 3/21/16 11:25 AM

The stage is set and the curtain goes up April 1. That’s when the Centers for Medicare & Medicaid Services’ (CMS) new Comprehensive Care for Joint Replacement (CJR) value-based payment rule will take effect.

This marks the first time CMS has required participation in a value-based program. In the CJR model, hospitals are financially responsible for the quality and cost of an “episode of care” for hip and knee replacements, from admission all the way through 90 days post-discharge. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries. Honestly, hips and knees are likely just the beginning. Consider this “Act One” of bundled payments for common inpatient surgeries.

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Topics: Healthcare Reform, Care Transitions, Medicare Readmission Penalties

Focus on Medication Management Translates to Real Dollars, and Real Sense

Posted by Wayne Sensor on 6/23/15 3:00 PM

Medication adherence is key to reducing 30-day readmissions and return ER visits

A recent article in H&HN Daily tells the story of Chicago-based Mercy Hospital & Medical Center and its quest to maintain better medical oversight of patients being discharged.

For organizations such as Mercy, who serve an estimated 300,000 at-risk, uninsured patients, the need to create innovative programs to help reduce readmissions is rooted in their very mission, but also in the practical realities of today’s health reform. Increasing penalties for avoidable readmissions is an outcropping of the Affordable Care Act and finding ways to reduce repeat emergency room visits that result in readmission translates into real dollars and cents.

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Topics: Healthcare Reform, Care Transitions, Patient Outcomes, Healthcare Technology Solutions, Reducing Readmissions