Improve Transitions to Drive Outcomes Under Value-Based Care

By Luis Castillo, President & CEO, Ensocare
Twitter: @EnsocareCircle

2019 may go down as the year value-based care comes into its own.

More facilities than ever have reimbursement tied to the long-term value they bring to patients; if your patients are re-admitted within the 30-day window, that’s going to create negative consequences for your reputation and your bottom line.

The care transition process is one area that’s often overlooked when evaluating how to ensure high-quality care following patient discharge. That’s despite the fact that transitions have an outsized impact on whether or not a patient who leaves your care is going to return to your care again in the near future.

With this in mind, let’s look at some of the factors that play in to a successful care transition and how you can improve your own hospital system policies.

Timing Is Everything
One of the biggest factors in determining whether or not your organization’s transition processes are set up for success within a value-based care structure is time.

If you can’t immediately find a post-acute bed for a patient, their odds of being readmitted actually increase. There’s a strange paradox at play where hospital admission helps in the recovery until the precise moment recovery is ready to be discharge; at that point, the odds of maintaining stability actually go down. That’s because the individual remains at risk for infections, their rest schedule is out of sync with their internal clock due to being in an unknown, inherently uncomfortable environment, and they’re not getting the assistance they need from a post-acute facility. In this way, their stay in the hospital actually inhibits the ability to follow the care plan!

That means graduating the patient to the next level of care quickly is essential. The sooner you can start the transition process, the better, even if that means anticipating the need for a transition before the acute care process is actually complete.

Of course, that means you need people available who can focus on transitioning the patient to the next level of care.

It’s difficult to minimize the acute stay when the task of placing a patient in a post-acute setting is relegated to nurses or other staff members who already have their hands full with other essential administrative tasks. Because such persons typically tend to focus on care first and foremost, the transition process isn’t prioritized.

One of the best ways to minimize long-term acute stays is to have personnel specifically tasked with overseeing this process. Discharge specialists who can find your patients the right post-acute setting can be a boon to response times, limiting your risk and ensuring you’re set up to succeed in the era of value-based care.

To really put a dent in lengthy post-acute stays, you also need a technology solution that streamlines the discharge process like never before.

If you’re still relying on someone to be on the phone all day, or to stand in front of a fax machine feeding copious amounts of paper into an antiquated piece of technology, you’ll always be hamstrung when aiming for speedy transitions.

The modern discharge process must rely on software to find the right bed for the patient. Tools that enable you to pull up your patient’s Electronic Health Record and then send that information safely and securely to the facilities that match their needs. Within minutes, the facilities in your post-acute network can respond to let you know if they have a bed available or if they’re at capacity.

In this way, technology itself enables you to improve your post-discharge process and prove your value to patients.

Matching Care Needs with Care Provisions
Technology can also play a role in ensuring your patients are being admitted to the post-acute settings that actually fit their needs.

By comparing quality metrics, specialties, staffing levels, types of services offered, insurance accepted and distance from the individual’s home, you can narrow down the list of potential post-acute suitors to those that would most conceivably help the patient.

When you present these choices and only transmit referral requests to those that are applicable, you can take another large step in reducing the window of time that the patient will remain in acute care. And because you know the patient has been matched with a facility that can best meet their needs, you’re further reducing the risk that they’ll be readmitted.

Another factor you’ll want to consider when evaluating your facility’s ability to embrace value-based care is the patient’s transportation needs.

The first form of transportation is going from the hospital to the post-acute facility. Whether it be via an ambulance, a ride-share service or a family member who understands the patient’s needs, it’s in your best interest and your patient’s best interest to schedule this transportation and then follow up to make sure everything went well. The last thing you want is a surprise when your patient is checked back in to the hospital and you discover it’s because her Aunt Bertha thought she’d be better off at home rather than at the inpatient rehabilitation service.

You also want to consider setting your patients up with transportation services that go beyond just making the acute-to-post-acute journey. One of the key factors of recidivism is your patient’s ability to keep appointments with members of their care team. If you can address the transportation disparity, you’re basically taking out an insurance policy that the person will stick to the care plan.

Post-Discharge Contact
Finally, how you interact with the patient post-discharge affects their chances of recovery as well.

Earlier, we discussed how having personnel exclusively responsible for discharge can limit the patient’s exposure to hospital-based risks. The same concept applies to the patient once they leave the facility.

A cadre of case managers on staff enables you to keep in contact with patients after they leave your facility. They can monitor those persons’ vital signs, their recovery efforts and their general state of being for 30 days, 60 days and longer. This gives you a real-time view into their post-acute journey. More importantly, it helps you judge your own intrinsic value, eliminating surprises that bring down your quality scores.

Tasking a nurse or some other staff member with fitting these responsibilities into an already-packed schedule is a recipe for failure. It’s critical to dedicate staff members to this task as the main part of their job.

Value-Based Care is Here. Are You Ready?
Value-based care isn’t going anywhere. Hospitals are being judged on helping people stay healthy, and the care transition process is a make-or-break moment for that evaluation.

By addressing time spent in hospital and the various factors that contribute to the patient logjam, you can take the first step in improving your readmission scores. And by subsequently monitoring your patient in the post-acute space and intervening as necessary to keep them on track, you further enhance your quality scores.

Healthcare is evolving. Addressing these needs will ensure you can evolve right along with it.

This article was originally published on Ensocare and is republished here with permission.