Improving Transitions of Care While Reducing Administrative Burden

Kelly Ambrose, BSN, RN, CHPN, Clinical Manager, Advanced Illness Care team, Housecall Providers - Print  | 

Some of our nation’s most vulnerable patients are the millions of individuals who are home-limited or entirely homebound.

Providing health care services right in a patient’s home requires careful collaboration to give them the care they need without relying on the hospital or emergency department (ED).But in a field where successfully managing transitions of care is crucial, providing top-notch care and meeting the regulatory guidelines for administration can be tricky — if not impossible — without the right resources. 

The challenges of managing transitions for complex patients

At Housecall Providers, many of our patients are frail or have complex care needs. Many are navigating disabilities, multiple chronic conditions or serious illnesses at the end of their lives. These complexities can make it difficult for an individual to go to a provider’s office for basic healthcare — especially if the patient has comorbid conditions.

Home-based care helps these patients access the care they need, which, in turn, helps keep them out of the hospital. Research published in JAMA Internal Medicine has found that home health care has been associated with cost savings of nearly $5,400 per beneficiary when compared to post-acute care in a skilled nursing facility. However, it’s critical to ensure that home-based care is effective to avoid costly readmissions. And effective care begins with successful collaboration between hospitals and post-acute services like home health and other home-based services.

To provide the best care possible, my team and I found ourselves calling different hospitals to coordinate patient care for the most vulnerable members of our community. This was a long and time-consuming process that meant we were spending far more time on the phone and administrative tasks than we were caring for our patients. Even with our exhaustive efforts, manual coordination was not entirely effective. In some cases, we were losing patients simply because we were unaware when they were hospitalized. Losing patients meant that we were missing out on providing timely follow-up, which impacted our ability to effectively meet quality metrics around transitions of care.

The financial and emotional toll of administrative burden

Health care practitioners and staff spend a significant amount of time each week making calls or completing documentation related to insurance, billing, legislative requirements and electronic health records. According to a recent study published in the Annals of Internal Medicine, administrative costs in the U.S. reached $812 billion, or 34.2%, of the nation’s total health care expenditures in 2017. (The study examined administrative costs of home care agencies, hospitals, physicians, hospices, nursing homes and insurance overhead.)

But administrative burden can lead to much more than high financial costs. One study found that physicians spend nearly a quarter of their time on administrative tasks related to patient care, with primary care physicians spending 33% of their time on administrative tasks. Most of these physicians reported that these administrative duties negatively affected their ability to provide high-quality care.

Additionally, a study of burnout in U.S. health care professionals found that more than half of physicians and more than one-third of nurses experience burnout, with administrative tasks topping the list of the reasons why. By reducing or improving the efficiency of administrative work, we can empower all health care workers to provide high-quality care for our nation’s most vulnerable patients.

The critical role of interoperability and automation

As the Centers for Medicare & Medicaid Services (CMS) pushes for greater interoperability between hospitals, primary care and post-acute providers, some cringe at the thought of spending countless hours sifting through databases, logging into different portals and an inbox full of software emails. But interoperability — when done right — can reduce administrative burden and the financial and mental costs associated with it.

The key to effective interoperability is using automation to your advantage. At Housecall Providers, we implemented Collective Medical — an ADT-based care collaboration platform — to help us reduce the administrative burden of caring for our 2,300 patients (including 120 served by our Advanced Illness Care Team). With the platform, we no longer need to call different hospitals looking for our patients. Instead, we are notified whenever a patient is admitted, discharged or transferred from the hospital, allowing us to quickly follow-up with appropriate care.

The platform is completely automated, and real-time notifications are integrated directly into our workflows. Studies show 49 to 96% of alerts are overridden, which leads to desensitization. By setting parameters around what triggers a notification, we can decide what information we need and what we don’t, preventing alert fatigue. These alerts have helped automate the communication our staff has with neighboring hospitals and, in turn, helped streamline patient follow-up and transitions of care once we knew which patients had recently been to the ED or hospital.

Freeing up time to focus more on patients

Year after year, Housecall Providers is one of the highest-performing CMS Independence at Home sites, with savings in Medicare patient health costs ranging from 15.7% to 32%. By moving health care into the home and improving transitions of care, we have been able to provide better care and save on costs for those who may otherwise rely on the emergency department or hospital for care due to physical, social or cognitive barriers. By reducing the administrative load on our team through real-time alerts, we’ve been able to spend more time focused on providing exceptional patient-centered care to homebound and seriously ill individuals in our community.

Related Reading: Losing Mom: The circumstances impacting maternal mortality and morbidity in the US

Kelly Ambrose is the Clinical Manager of the Advanced Illness Care team at Housecall Providers – one of the few community-based palliative care programs in the United States focused exclusively on a safety-net population. Kelly has more than 15 years experience serving vulnerable patients in community settings.

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