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Blog | Operations Management

Optimizing Care Transitions

Blog | Operations Management

Optimizing Care Transitions

Luis Castillo describes how healthcare organizations can help patients make smoother transitions to post-acute facilities.

Managing a patient’s departure from the hospital to a post-acute setting can be time consuming for hospital discharge planners and care management staff. Unless the patient already has an arrangement with a specific facility, patient placement typically involves a lot of back-and-forth communications that quickly swallow time. Given how many patients are released from a hospital each day, it is easy to see how case managers can spend upwards of half their work week—21 hours—planning and coordinating discharges. Unfortunately, more time devoted to the task does not necessarily translate into better post-acute placement.

Discharge Challenges: An All-Too-Common Example

Consider the example of an elderly inpatient treated for a stroke who needs to be moved to a post-acute care facility. The patient’s case manager is both distracted and pressed for time from having to juggle several different patients’ discharges. The case manager starts calling and faxing several nearby post-acute care facilities with which the hospital has worked, trying to find a place that could accept the patient. After several days of following up and trading messages, the case manager hears back from one organization that has availability. Because the patient is already a day past due for the discharge, the case manager is eager to facilitate the transition.

Unfortunately, once the patient arrives at the facility, the family learns the location does not offer the occupational therapy the patient requires. Somewhere in the transition, the need for that type of therapy was not communicated to the case manager, who therefore didn’t look for facilities that offered this option. In addition, the post-acute facility has limited visiting hours, which restricts how much time the patient’s husband can spend with her, which goes against the patient’s wish to have her husband by her side for most of her post-acute care treatment. Again, this information was not communicated to the case manager. After a few weeks, the patient, underserved at the post-acute facility, is readmitted to the hospital. Not only are the patient and family frustrated by this outcome, but also hospital is negatively impacted. The clinical, financial, and emotional ramifications are challenging for all involved.

A Redesigned Process

Fortunately, there are ways to minimize many of the problems reflected in the previous example. Here are three tactics for revamping discharge that can not only yield greater efficiency but more positive patient outcomes as well.

Start the process early. Hospitals should begin the discharge process almost as soon as the patient is admitted for treatment. Physicians and nurses already may have a reasonably clear idea of what type of post-acute care a patient will need, and they should start communicating early on with the discharge planner and the patient and family about various care requirements. Communicating this information in writing can be especially beneficial. Armed with all the necessary data, the discharge planner can look for an organization that meets the patient’s specific needs. Also, by starting the process earlier, discharge planners won’t be as rushed, allowing more time to thoroughly vet a potential organization.

Review staffing. Discharge is a high-risk time in which vital information can be lost and care lapses may result. Healthcare organizations should take a close look at their discharge-planning and case-management staffing arrangements to ensure the workload is well enough balanced to prevent things from slipping through the cracks. This step is especially important during off-peak times. Patients aren’t always discharged between 9 a.m. and 5 p.m., and both hospitals and post-acute care organizations need to be fully prepared to meet patients’ needs. Organizations also should make sure their staff are well trained on how to support the discharge process and interact compassionately with patients.

Make effective use of technology. Automated care coordination solutions can help organizations avoid many of the challenges present in care transitions. Using this kind of technology, a case manager can swiftly enter all of a patient’s specifications and requirements for post-acute care, receive a generated list of organizations that meet the specified criteria, and assist the patient and family in choosing the best viable option. Once a patient is discharged, hospitals can establish a virtual command center to which all members of the patient’s care team—both within the hospital and outside of it—can connect to monitor the patient’s progress and address issues that may result in a readmission.

By implementing an efficient process that starts early in the patient’s encounter and is performed by well-trained staff, a healthcare organization can improve patient outcomes and mitigate readmission risks, thereby also improving patient satisfaction and promoting greater patient loyalty and retention.

Luis Castillo is the president and CEO of Ensocare, Omaha, Neb. 

About the Author

Luis Castillo


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