Helen's Post-Acute Journey - Part II

Posted by Jill Reeves, MHA on 5/15/17 10:21 AM

The Next Step on the Journey to Recovery

It’s Helen’s first day at the post-acute facility. As you may recall, she was discharged from the hospital to further recover from surgery. She and her family are extremely grateful the hospital medical team and discharge planners were able to use an automated discharge process tool to efficiently match her with just the right post-acute provider. The new organization has both the physical and occupational therapy services she requires, as well as the nutritional counseling she needs.

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Topics: Post-acute Care, Care Coordination

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

Strengthening Post-Acute Networks

Posted by Jill Reeves, MHA on 1/16/17 8:00 AM

A strong network of facilities ready to receive a patient and seamlessly continue his or her care is a key element in transitioning patients out of the hospital and into the post-acute setting. Although large health systems often have capable networks based on the amount of patients they feed into these facilities, small- to mid-sized hospitals can lack the leverage of larger organizations and may have much less robust networks as a result. Though patients are the ultimate decision makers regarding which facility they will transition to after hospital discharge, network limitations can mean the hospital has fewer options to share. If this leads to a patient making a less-than-ideal choice, it can potentially impact the individual’s health outcomes, as well as satisfaction. As such, hospitals and health systems need to strengthen their networks in order to provide favorable recommendations for the next care stage.

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Topics: Post-acute Care

IMPACT Act Brings Post-Acute Care Transitions to the Forefront

Posted by Mary Kay Thalken, RN, MBA on 5/30/16 8:30 AM

Through the use of standardized quality measures and standardized data, the intent of the IMPACT Act, among other obligations, is to enable interoperability and access to longitudinal information for such providers to facilitate coordinated care, improved outcomes, and overall quality comparisons.

Quality Measure Domains:

  • Skin integrity and changes in skin integrity
  • Functional status, cognitive function, and changes in function and cognitive function
  • Medication reconciliation
  • Incidence of major falls
  • Transfer of health information and care preferences when an individual transitions
Click here for Resource Use and Other Measure Domains.

By the end of 2014, 97 percent of all U.S. hospitals had met the foundational requirement of Meaningful Use 1 by having installed certified electronic medical records (EMR) technology. This achievement marks an important first step in the Centers for Medicare & Medicaid Services’ (CMS’) wide-scale effort to construct the technology infrastructure needed to bring the first real change to healthcare in decades. This foundation is absolutely essential to support the relentless drive toward a fee-for-value system.

A system that once rewarded hospitals financially for doing more procedures, is now demanding that if these procedures be done, they are done well. This greater push toward value brings the challenge of how to standardize communication among disparate providers to ensure patients receive the continuity of care required to prove and achieve quality outcomes.

As a result, healthcare organizations today are scrambling to keep up with the many new government initiatives, measurement, reporting, subsequent penalties, and standardization required to compete in the changing environment. The foundational investment made in the EMR was just the beginning. The challenge now is to make that system, and the many disparate systems that are used throughout the care continuum, to somehow speak a mutually agreeable vocabulary.

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Topics: Post-acute Care, Care Coordination, Healthcare IT

The Brave New World of Patient Involvement in Care

Posted by Wayne Sensor on 4/14/15 10:15 AM


It’s no secret to anyone that health care is an ever-evolving industry. But some people and organizations in health care are stepping into the brave new world of inviting patient and family advisors to partner on projects related to quality and safety.

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Topics: Post-acute Care, Care Coordination, Care Transitions, Patient and Family Engagement, Patient Satisfaction, Healthcare IT

Data, Technology Offer Sustainable Solutions to Address Readmission Risks

Posted by Wayne Sensor on 2/18/15 10:31 AM

I’ve had the privilege of talking to hospital administrators across the United States about the creative BLOG_Emergency_Roomstrategies being implemented to address the triple aim of the Affordable Care Act. One major outcome of health-care reform that I hear discussed time and again pertains to the associated migration of risk from the payer community to the provider community.

The one thing nearly all find problematic is identifying solutions to mitigate the financial risk of avoidable readmissions. This is not an easy task and one that can prove quite costly for organizations from both a time and financial standpoint.

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Topics: Post-acute Care, Care Coordination, Healthcare Reform, Reducing Readmissions

Using Your Post-Acute Network to Reduce Readmission Penalties: An ANI Sneak Preview

Posted by Wayne Sensor on 6/12/14 9:22 AM

Last year, two-thirds of eligible hospitals felt the blow of readmission penalties, which totaled $227 million, according to the Healthcare Financial Management Association. Since CMS announced it would enforce these regulations, hospitals have been searching for effective strategies to address the complicated factors involved with readmissions.

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Topics: Post-acute Care, Care Coordination, Healthcare Reform, Medicare Readmission Penalties, Ensocare News

Breaking Down Barriers to Effective Care Coordination

Posted by Wayne Sensor on 6/4/14 9:47 AM

At the National Readmission Prevention Collaborative Summit a few weeks ago, I spoke about the challenges health-care organizations face today in facilitating effective care coordination and how addressing those challenges can impact the patient experience.

Namely, when discharge planning and care coordination are successful, hospitals and health systems are better equipped to navigate patients through the care continuum, reducing readmissions and ultimately improving patient outcomes. However, realizing effective care coordination can be challenging as there are several barriers organizations must first overcome.

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Topics: Post-acute Care, Care Coordination, Length of Stay, Healthcare Reform

Reducing Readmissions: A Better Way

Posted by Kyle Salem, Ph.D. on 5/19/14 10:14 AM

Did you know that nearly 80 percent of serious medical errors involve miscommunication during patient transfers? Doesn’t that illustrate the need for accurate and timely information exchange in discharge planning?

There’s got to be a better way—one that benefits patients and providers.

Hospitals are employing nontraditional best practices to improve communication and avoid penalties. Consider the following strategies many facilities use to support robust patient care across the continuum.

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Topics: Post-acute Care, Care Coordination, Reducing Readmissions

Part II: Four Steps to Maintain Patient Engagement after Discharge

Posted by Mary Kay Thalken, RN, MBA on 5/5/14 12:37 PM

Editor’s Note: This is the second of a two-part blog series. Read the first blog here.

In my blog last week, I talked about the fact that engaging patients in their care is essential to care quality, increasing patient satisfaction and achieving positive patient outcomes.

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Topics: Post-acute Care, Care Coordination, Care Transitions, Patient and Family Engagement, Patient Satisfaction