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Best Practices for Hospital Discharges to Post-Acute Sites

By Wayne Sensor of Ensocare

By designing the hospital discharges to be efficient, patient-centered, and data-driven, hospitals can go a long way toward ensuring positive outcomes.

- When hospitals discharge patients to post-acute settings, they must give up a modicum of control and trust that a post-acute provider will fully meet a patient’s health needs and deliver safe and optimal care.

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While it used to be this lack of influence had no direct impact on hospitals, times are changing as organizations assume more risk regarding patients’ long-term health outcomes. In addition to the negative clinical consequences a poor post-acute experience can cause, there are now significant financial ramifications for hospitals, both in terms of readmission penalties and also reduced opportunities for value-based reimbursement.

Although a hospital is limited in what it can do to improve post-acute care, it can lay the groundwork for a successful transition. More importantly, by designing the discharge process to be efficient, patient-centered, and data-driven, hospitals can go a long way in mitigating post-acute risks, elevating the patient’s overall experience and yielding better clinical and financial outcomes.

Following are five best practices for achieving a robust discharge process.

1. Start at the time of admission

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It’s never too early to start discharge planning. By beginning to map out the patient’s transition as soon as admission, a hospital can support a smoother process, avoiding unnecessarily extending the length of stay (LOS) and limiting potential care gaps. Although a hospital may not be able to pinpoint an exact discharge date, in most cases it can reasonably predict one using the mean LOS for the patient’s diagnosis as long as no contra-indicators exist. In addition, clinicians can often anticipate what the patient’s condition and prognosis will be at discharge based on his or her diagnosis and current condition, allowing providers to start planning for post-acute needs upfront.

2. Engage the patient and family early

Too often, hospitals wait until the day before discharge to involve families. This can place unnecessary stress on the patient and family and potentially extend a patient’s LOS if the family is not able to quickly select a post-acute provider. By initiating discharge planning at admission, providers have more opportunities to engage patients and families throughout the process, helping the hospital gain a better appreciation for the patient’s perspective. Moreover, it can ease some of the anxiety involved in selecting a post-acute facility and allow enough time to identify the most appropriate setting with which the patient and family feel comfortable.

3. Ensure the patient understands discharge instructions

Many hospital readmissions occur because patients don’t understand their diagnosis and next steps for care, including how and when to take medications. As such, it is especially important to provide thorough and patient-centered education that gives the patient and his or her family a complete understanding of their post-acute care plan, including the patient’s role in his or her care. Clinicians should consider the patient’s health literacy and learning preferences when providing education. Communication strategies such as “Teach Back” can help verify the patient fully understands the information provided and can follow medication and treatment regimens.

READ MORE: Communication, Health Data Exchange Lags Between Hospitals, PCPs

4. Match patients’ needs with post-acute providers’ services

When planning a patient’s discharge to a post-acute facility, the hospital’s primary goal should be to find the most appropriate provider so the patient receives optimal care and has the best possible chance of recovery. For instance, if a stroke patient will require speech, physical, and occupational therapies, the hospital should ensure the patient will be discharged to a facility that can accommodate these needs. Failure to properly match a patient’s clinical, psychosocial, cultural, and ambulatory needs could impact the patient’s recovery, quality of life, and readmission risk.

5. Make sure meaningful clinical information flows from the hospital to the post-acute setting

A post-acute provider that receives comprehensive information from the discharging hospital is more likely to provide appropriate and timely care that continues the treatment plan and supports positive patient outcomes. Although it may be tempting for a hospital to give the post-acute provider the patient’s complete medical record, this can be overwhelming, since it is not uncommon for patient files to run dozens — or even hundreds — of pages. If hospitals send these unwieldy documents in their entirety, how will the next provider know what information is relevant and what is not? Will they even attempt to read a document if it is too long? Rather than sharing an entire file, hospitals should instead extract and send the most meaningful and relevant information to affect a successful handoff and support the patient’s care continuity.

Adopting best practices yields measurable results

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A hospital can carry out the aforementioned practices manually or by leveraging technology, such as automated discharge and care coordination solutions. Although hospitals can see benefits from either approach, employing technology can greatly increase the scalability of interventions. Hospitals moving from a manual to an automated discharge process, for instance, can see LOS reductions of up to one full day for patients going into post-acute facilities. Because a vast majority of reimbursement — especially Medicare — is set by diagnosis and mean LOS, this improvement can substantially affect an organization’s bottom line.

Consider the example of a large Midwestern medical center that examined how implementing automated discharge technology affected business. After measuring for six months, the organization observed a significant LOS impact for post-acute handoffs. Specifically, LOS for patients discharging to skilled nursing facilities dropped by 5 percent; home health agencies by 12 percent; and acute rehabilitation hospitals by 8 percent. For this organization, those reductions alone translated into $1.2 million in savings.

Additionally, automating the discharge process can increase workflow efficiency and staff productivity, freeing hospital resources to focus on more complicated cases. For example, most hospitals employ entire fleets of discharge planners and care coordinators who spend up to 50 percent of their time — or 20 hours per week per provider — on clerical functions related to discharge, such as placing inquiry and follow-up phone calls and faxing documents.  Leveraging automated discharge technology, hospitals can reduce the time spent on clerical functions by as much as 75 percent — cutting administrative tasks to only 5 hours per week per provider. This gives staff more time to interact with patients and initiate interventions when necessary.

Whether or not hospitals choose to use technology, embracing the five practices outlined above is key to improving the discharge process. From a business perspective, adopting these practices can positively impact the organization’s balance sheet. From a patient-care perspective, it allows a hospital to effectively support care continuity between settings and facilitate the optimal patient experience and outcome.

Wayne Sensor is CEO of Ensocare.




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