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5 questions with naviHealth's Heather O'Sullivan on discharge planning

Despite recent technological advancements, clinicians still struggle to coordinate with their peers outside of a hospital's four walls.

This challenge poses a particular barrier when discharging patients to post-acute organizations, such as skilled nursing facilities or home health agencies. Clinicians not only need to hand off patient data from one organization to the other, but also must work with each other to establish appropriate discharge and long-term care plans.

"Having all the relevant information about a patient in one place and having the ability to review documentation in prior care settings reduces administrative burdens for clinicians and reduces the risk of error or delays for patients," explains Heather O'Sullivan, chief clinical officer of naviHealth, a Cardinal Health company that manages post-acute care transitions.

Ms. O'Sullivan has nearly two decades of experience in clinical, operational and leadership roles at healthcare organizations, along with eight years spent as a nurse practitioner. "Recently, I heard some discharge planners are spending as little as 90 seconds talking to a patient about his or her transition plans," she says. "I believe we can do better."

Ms. O'Sullivan spoke with Becker's Hospital Review about how clinical decision support and enhanced communication technologies can improve the discharge planning process.

Editor's note: Responses have been lightly edited for length and clarity.

Question: What challenges do clinicians at hospitals and post-acute care facilities face when coordinating with one another?

Heather O'Sullivan: Some hospital-based clinicians, such as discharge planners who still use manual, fax-based processes, spend, on average, one to two hours processing a post-acute placement for a single patient. Often, they are making 10 to 15 calls per patient to post-acute facilities, playing "phone tag," sending documents or performing other administrative tasks, instead of spending time on direct patient care. This creates undue stress and burnout and can negatively impact clinician-to-clinician relationships, not to mention the quality of care for patients in transition.

I wish it were easier for post-acute clinicians, but, unfortunately, they also experience challenges. Intake staff must complete a detailed admitting process, while addressing questions from patients and their loved ones. Often this time is cut short as they seek out missing information from hospital case mangers or clarify care plans. In instances where a referral request is sent to dozens of post-acute providers, an intake coordinator can spend a significant amount of time on a case, only to find the patient has been placed in another facility. Regardless of where the slowdown or breakdown occurs, patients and families are the ones affected most.

Q: How does streamlining clinician-to-clinician communication influence patient outcomes?

HO: Streamlining communication during care transitions is critical to patient outcomes. The literature is clear on the matter: Poor handovers lead to an increase in medical errors, readmissions and acquired infections, as well as lower patient satisfaction. For example, with one hospital partner, we leveraged our relationships with case managers to improve communication with home health agencies prior to discharge, increasing patient adherence with home health orders and lowering readmissions. Now, with a shift to value-based care, hospitals and post-acute providers cannot afford a breakdown in communication, especially during transitions.

Q: How does naviHealth use technology to intervene in clinician-to-clinician communication during care transitions?

HO: naviHealth deploys a care transitions platform to facilitate discharge planning and uses clinical decision support tools to drive discharge care plans tailored to each patient's needs. Our tools and technology are designed with the clinician in mind, so they capture vital information about the patient that can be accessed across care settings. For example, a naviHealth care coordinator in a SNF can review and update risk assessments and care plans that were completed by a care coordinator in the acute hospital. Another example is the intake coordinator can quickly review discharge information about a patient before he or she is transferred to the SNF.

Q: How does naviHealth ensure patients have a voice during care transitions?

HO: Keeping the patient at the center of what we do is embedded in our core values. For us, being patient-centric starts at the top. Our leadership team believes in it, and it is woven into the fabric of our company culture. On a local level, our nurses and therapists engage patients and their families in hospitals, post-acute facilities and in the community. We use our decision support tools, proprietary data and insights — e.g. severity-adjusted SNF quality measures — and clinical experience to empower patients to make informed decisions. Families are involved in care planning, and patients receive individualized discharge plans to meet their needs and enable them to self-manage their conditions.

Q: What advice do you have for hospitals working to improve clinician-to-clinician communication with outside organizations?

HO: First, we need to acknowledge there are numerous barriers to clinician-to-clinician communication, not to mention communication with community-based care providers and social services. They are internal and external, and some, like the lack of interoperable IT systems, can seem insurmountable. But, my advice is this: Be fearless in pursuit of what's best for your patients and be willing to take risks.

None of the challenges hospitals face will be solved overnight, but we should be creative and innovative when it comes to new ways of communicating. There are countless low-tech and high-tech solutions available to clinicians, from area councils of providers and community-based services to secure messaging and mobile apps. Of course, not every solution will work for every organization, but explore options that might work for yours — then try it! A pilot can be a great way to test new technologies, processes or structures without widespread disruption. The status quo isn't working for clinicians or our patients. We have to find a better way, together.

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