By Alex Moran, CEO and Founder, Roost
LinkedIn: Alex Moran
LinkedIn: Roost
We have become very good at telling the next provider that a patient has left the hospital. We have built almost nothing for hearing what happens after that. I find that strange, because the people with the best view of a person’s condition after discharge are usually not in a clinical setting at all. They are in the home, and they are there several times a week.
A home care worker who sees someone four times a week knows what normal looks like for that person. They notice when getting out of a chair takes two attempts instead of one. They notice the drinking, the eating, the confusion that was not there on Tuesday. They notice a change in mobility that is nowhere near dramatic enough to trigger a clinical intervention but is clearly different from last week. Those changes often show up days before a crisis. In my experience they almost always go nowhere.
I have sat in care reviews where the caregiver’s notes from the week before a readmission described exactly what was coming. Reduced fluid intake on the Monday. A change in mobility flagged on the Wednesday. An ambulance on the Friday. Everything a clinician would have needed was written down, in our system, where nobody outside our organization was ever going to read it.
Under the CMS Conditions of Participation, hospitals have to make a reasonable effort to send admission, discharge and transfer notifications to applicable post-acute providers. The hospital tells the next provider what has happened and where the patient is going. Then the flow stops.
The agency takes the notification, starts caring for the person, and hears nothing further until that person is back in the emergency department. I do not think that is a neighborhood health system. It is two organizations taking turns. The hospital carries the financial consequence of the readmission. The person who could have called it was in the kitchen four days earlier.
We have spent years putting technology into every part of healthcare. Electronic records, health information exchanges, increasingly sophisticated ways of moving information between organizations. We have done almost none of that work in the setting where most of the relevant information is actually being generated.
That setting is the home, and it is where neighborhood health infrastructure has to start. Not a building and not a new tier of service. A working link between the people who see the patient most often and the clinicians who carry responsibility for them. So the question I would put to a health system is not whether the systems can talk to each other. It is whether you have given the people in the home a reason, and a requirement, to send anything back.
Starting is not complicated. Decide what you actually want to know about a patient receiving care at home. Mobility. Appetite. Hydration. Medication adherence. A change in cognition. It does not need to be a 30-question assessment and it should not be one. Five or six observations recorded the same way on every visit will tell you more than a long form nobody completes properly. Have the provider record them during the visit and return them on an agreed schedule. Then put that exchange into the relationship between the two organizations. Make it a condition of sitting in the preferred post-acute network. That is a different conversation about interoperability. It moves from “can your systems connect?” to “as one of our preferred partners, are you going to give us what we need to manage outcomes in this community?”
The second question is the one that matters. We have treated interoperability as an IT problem for a decade. Standards, interfaces, whether one system can speak to another. All of it necessary. None of it tells us what information should move, how often, and who is accountable when it does not arrive. No standard decides what a carer should write down when a patient who walked comfortably last week is now holding the wall between the bedroom and the kitchen. A neighborhood health system decides that. So does a contract.
Once the information moves, the decision can move with it. That is the part I care most about. A clinician looking at a week of consistent observations from the home can act where the patient is. Change the medication, send someone in, adjust the plan. The alternative is an ambulance and an assessment unit that spends its first hours reconstructing exactly the week the home care worker already had written down. That is the prize. Not data exchange for its own sake. The ability to make the clinical decision in the neighborhood instead of in a hospital bed.
Which is why I think most post-acute selection criteria are wrong. Referral volume, existing relationships, convenience. If readmissions matter to me as a health system, I want partners who can tell me what is happening to my patients between the visit to the doctor and the visit to the hospital, and I want to handle most of those deteriorations at home rather than through processes that slow patient flow and start the assessment from zero. And if I am running a home care organization, which I am, I should be able to prove I provide that visibility. If I cannot, I am asking to be chosen on convenience.
None of this turns carers into clinicians or asks hospitals to swallow a flood of unstructured observation. The opposite. Agree a small set of things that matter, record them consistently, get them to someone who can act. We have spent years working out how to push information out of the hospital. We should spend some of that effort working out how to get useful information back, and then on giving clinicians a way to act on it where the patient actually is.
Discharge is not the end of the patient’s story. It is the end of the hospital’s view of it. Those are two very different things, and we have been running the system as though they were the same. The technology for a return path is already here. What is missing is the expectation that it will be used, and the neighborhood infrastructure that makes it worth using. That is not an interoperability problem. It is a contracting decision.