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, Health-care Technology Solutions

Using Technology-enabled Care Coordination to Boost Quality Outcomes

Posted by Kyle Salem, Ph.D. on 6/6/16 10:30 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.

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Topics: Health-care IT, Health-care Technology Solutions

Enhance Patient Satisfaction and Engagement Using Technology-enabled Care Coordination

Posted by Kyle Salem, Ph.D. on 5/25/16 8:36 AM

May 24, 2016 - Becker's Hospital Review

Hospitalized patients often experience a multitude of feelings—anxiety, fatigue and fear, not to mention possible pain. For those who require further treatment or recovery at post-acute facilities, a poor transition can heighten these feelings, adding stress to an already difficult situation.

Historically, post-acute patient placement has been a manual, somewhat impersonal process. Although case managers or discharge planners usually give the patient a list of possible post-acute facilities to consider, they commonly leave research and decision-making entirely up to the patient and his or her family. Additionally, when it comes time to transfer out of the hospital, the patient's medical record might—quite literally—travel on his or her lap to the receiving facility. Sharing medical records and discharge activities in such a disjointed, unconnected, way can lead to medication or medical errors, gaps in care and even unfavorable outcomes.

Discharges like these don't afford much opportunity for high-touch care, which most patients need during transition periods. Moreover, these types of discharges don't guarantee patients will transfer to a facility that is prepared to receive them or that can effectively meet their clinical or personal needs. If individuals are inappropriately placed, it can affect their overall satisfaction, as well as their clinical outcomes and readmission risk.

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Topics: Health-care IT, Health-care Technology Solutions

The Boost Your EMR Needs to Be a Care Coordination Machine: a Healthcare Executive’s View

Posted by Wayne Sensor on 5/19/16 11:01 AM

More than a decade ago when the healthcare industry began transitioning from paper charts to electronic medical records (EMRs), leaders of large hospitals and health systems, including me, expected to see at least some return on investment. Yet over the years, it has become apparent EMRs alone cannot produce the clinical and financial returns once anticipated. Today’s EMRs need a technology booster shot to take them from electronic repositories of patient data to a vehicle that supports the free exchange of protected patient health information among care providers and even with patients themselves. If they get the boost they need, I believe EMRs will be the lone platform needed to fundamentally transform fee-for-service medicine to fully coordinated patient care.

So where do we start? First, leaders should accept that their EMR system is a living, breathing infrastructure platform which will require regular updates and investments to effectively manage healthcare information in a complex, constantly changing healthcare environment. Perhaps the biggest challenge is that our idea of care coordination is changing. Today, providers and payors are thinking and talking about “episodes of care” instead of discrete procedures. The data sharing that’s necessary to ensure continuity of care requires interoperability, and unfortunately post-acute facilities rarely use the same EMR system as the referring hospital. Bottom line, not everyone can read or access the information they need to fulfill their role.

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Topics: Health-care IT, EHRs, Health-care Technology Solutions

Getting Your Hands Around Health-Care Technology

Posted by Patrick Yee on 4/25/16 9:07 AM

Congratulations, if you’ve got a smartphone, you’re going to have a hand in health-care reform.

According to the Price Waterhouse Cooper Health Research Institute, 2016 is the year that care is going to shift, literally, into consumers’ hands – into their smartphones, to be exact. PwC surveyed consumers in 2013 and 2015 and identified a 100 percent increase in the number of consumers with at least one medical, health or fitness app. While there’s no doubt mobile medical app usage is increasing, not all of them are created equal. So far, real results for many apps have been hard to come by, and the Food & Drug Administration and the Federal Trade Commission are starting to crack down, particularly on apps that promise consumers that they can diagnose, or even treat disease.

Where I think mobile apps can have an even bigger impact is when they get in the hands of patients and their physicians. When physicians can set up patients with “anywhere-anytime monitoring,” receive the objective data from the mobile app and use it to consistently improve patient outcomes, that’s when mobile medical apps will truly come of age. Patients will absolutely play an important part in this shift, as they take advantage of less costly, but still effective telehealth services. Even when you factor in the cost to equip hospital departments to perform telemedicine, the projected savings over the cost of traditional care are significant. Automated solutions that can track and coordinate the care patients receive at multiple points along the health-care continuum aren’t just on hospitals’ wish lists anymore – they’re becoming reality. Viable apps are out and available in the marketplace today, and more are on the way.

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Topics: Health-care IT, Health-care Technology Solutions

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, Health-care Technology Solutions, Reducing Readmissions

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, Health-care Technology Solutions

Breaking Down the Walls in Health-care Technology

Posted by Patrick Yee on 9/15/15 10:08 AM

A stay in the hospital just isn’t like it used to be.

Today’s hospitals are becoming more wired. More of them have computerized physician order entry (CPOE) systems, electronic health records (EHR), and massive databases that grind through staggering amounts of information to improve the care and the outcomes patients experience.

But the majority of this “wired” action still seems confined inside hospital walls. That’s bad news for the 35.1 million people who were discharged last year from inpatient hospital settings. Millions of them still needed complex care and were overwhelmed at the prospect of having to handle everything from filling prescriptions to changing wound dressings to finding a post-acute care facility.

Today’s most wired hospitals are starting to connect with patients because the Centers for Medicare & Medicaid require it. That’s a good thing. Now they need to take optimization a step further and do it because it’s good for patients and their families. According to the 2014 National Healthcare Quality and Disparities Report, care coordination is one of six priorities that feeds into quality health care. But the same report notes that “there are few measures to assess trends in care coordination.” So we know it’s a priority. We know it matters. And we still have work to do. As a health-care professional, there are ways you can help remove the barriers to the optimized patient care experience.

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Topics: Health-care IT, Health-care Technology Solutions

Technology Solutions Enhance Common Readmission Strategies

Posted by Wayne Sensor on 7/23/15 9:39 AM

A recent article published by Becker’s Hospital Review named the six most and least common strategies used by hospitals across the country to reduce readmissions.

The most common readmission reduction strategies:

  1. Completing a medication reconciliation process
  2. Educating patients and caregivers before discharge
  3. Conducting phone calls or other communication post-discharge

The least common readmission reduction strategies:

  1. Conducting in-home visits post-discharge
  2. Using technology specifically designed to manage risk
  3. No formal strategy

As a former hospital and health system CEO, I have seen each of these strategies deployed with varying levels of success.  I have also come to realize that the time has come to capitalize on technology as a solution for reducing avoidable readmissions and mitigating the associated risk. Not only can technology bring new strategies into play, it also can work to make commonly-used strategies more successful.

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Topics: Health-care Technology Solutions, Reducing Readmissions

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: Health-care reform, Care Transitions, Patient Outcomes, Health-care Technology Solutions, Reducing Readmissions