Optimized patient discharge yields better outcomes

A prolonged stay in the hospital after a patient has already been cleared for discharge is a risky time.

According to a recent peer-reviewed study, the likelihood of serious infection—urinary tract infection, pneumonia or sepsis—increases dramatically the longer a patient remains in the hospital unnecessarily.

What’s concerning is that patients routinely spend too much time in the hospital waiting to move to the next level of care. Their discharge may be delayed for a variety of reasons, including a lack of availability in nearby post-acute facilities or inadequate home care services.

To combat the risks of a prolonged discharge, organizations must find ways to expedite the transition from the hospital to the next level of care.

Trading one challenge for another

The discharge process is complex, time-consuming and often uncertain. If hospitals and post-acute providers don’t communicate effectively with each other, there can be missteps, delays and miscommunication. If a patient requires physical therapy in the post-acute setting and is discharged to a facility that does not offer that type of treatment, he or she will not receive the necessary care and may end up back in the hospital.

Similarly, if a patient doesn’t have a clear set of instructions and input when released home, he or she may struggle to follow the discharge plan. Their recovery may regress and could result in a return trip to the hospital.

Consider the patient who is sent home with a complex set of medications but is confused about how or when to take them. Although the patient received instructions in the hospital, he or she may struggle to make sense of the directions or be unsure of who to contact to receive clarification. In this scenario, the patient may take the medications incorrectly or skip them all together – either approach having the potential for serious, even grave, consequences.

Or, if an organization rushes the discharge in an effort to reduce the likelihood of infection and other complications that can arise due to extended lengths of stay (LOS), it could potentially cause different problems in the future. In other words, the hospital may be swapping one hazardous situation for another.

The key is well-designed discharge

A well-structured, streamlined discharge process can address both issues—decreasing LOS while avoiding post-discharge communication breakdowns and lapses in care.

By starting discharge planning efforts early in the patient encounter, organizations allow plenty of time to determine the appropriate services and placement, communicating with the next care setting and sharing critical information.

Technology enables greater efficiency and reliability during transitions of care. Staff can use digital care coordination solutions to better connect patients with the right post-acute providers who are able to fully address the individuals’ needs—whether that means the location offers respiratory and physical therapy, satisfies the patients’ socio-emotional needs or meets other key requirements.

This technology also allows organizations to electronically send the patient’s medical record directly to the post-acute provider so the receiving organization has all the information it requires to treat the patient before the individual arrives on site. The post-acute provider can order therapies and medications ahead of time so the patient does not experience any lapses in care.

For those patients being transferred home, it’s critical to create an infrastructure that ensures all members of the care team—the hospital care coordinator, primary care physician, home health nurse, pharmacist and family—can effectively monitor the patient and share information in real-time. Again, automated care coordination tools can facilitate this collaboration to an unprecedented degree.

Serving as a digital command center, these tech-based solutions monitor patient compliance within a care plan. Patients use Bluetooth-enabled technology to upload their BP or weight, for example, into the care coordination software, allowing all care team members to monitor and intervene if readings become worrisome. The tool sends alerts if patients forget to upload readings or miss an appointment, and it notifies care team members of any other concerning changes in the patient. By leveraging this kind of solution, hospitals can make sure the patient complies with the care plan and continues to improve after he or she leaves the hospital.

Preserving patient safety

In the end, not only is an individual’s time in the hospital shorter, but his or her transition out of the hospital is smoother, resulting in positive outcomes and less risk of coming back to the hospital unnecessarily.

Mary Kay Thalken is chief clinical officer at Ensocare.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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