Leveraging technology to overcome care coordination hurdles

Hospitals and health systems are starting to recognize the value in coordinating care after patient discharge. The more these entities are able to communicate and collaborate with post-acute providers, patients, families and community support services, the greater the likelihood of reduced readmission rates and positive long-term patient outcomes.

Unfortunately, care coordination can be challenging for hospitals as there are a few roadblocks standing in the way, but as organizations work to eliminate these barriers, they are discovering the benefits of care coordination technology. Here are a few essential ways these solutions can help hospitals and health systems address care coordination hurdles and take post-discharge interactions to the next level.

Streamlining workflow. Organizations that use diverse clinical and administrative technology solutions often have different workflows depending on the systems they're currently using, and it can be cumbersome for staff to remember the various ways of performing different tasks, including those related to discharge communication. This can lead to frustration, as well as a lack of reliability as staff members don't always follow the correct processes. Fortunately, there are care coordination technologies that are able to integrate with larger EHR systems, so case managers and other providers can seamlessly transition into the care coordination solution. Not only does this enable them to perform at a faster pace and more efficiently, they also are less likely to make mistakes if they don't have to navigate multiple, diverse workflows.

Strengthening post-acute networks. While a lesser issue for larger facilities, many small to mid-sized community hospitals don't have a robust post-acute network on which they can rely. Even though the patient is the ultimate decision-maker as to where he or she goes after discharge, when the hospital has a list of qualified facilities it can recommend, the transition process is frequently smoother, as well as safer for all involved parties. Using care coordination technology, hospitals of all sizes can easily communicate with a vetted network of certified post-acute entities. With just a few mouse clicks, organizations can concurrently send detailed information about a patient's condition to multiple prospective providers and hear back within minutes as to which facilities can accept the patient. This allows the hospital to present a pre-qualified list of approved facilities to the patient and family, helping them make a more informed decision about the next care setting. Emerging mobile tools are making this process even faster. Using a smart phone or tablet, a post-acute provider can review the patient's information and decide almost instantly whether or not to accept the individual, prompting faster answers and greater efficiency, while further closing gaps in the patient's care.

Fostering transparency. Hospitals often lose sight of patients once they leave the acute setting. As organizations are held accountable for patient readmissions up to 90 days after discharge, the need to have better communication with post-acute providers and patients is becoming paramount. Organizations must find ways to keep patients in sight, whether that means speaking directly with post-acute facilities or the patients themselves. Once again, care coordination technology can help. When a patient selects a post-acute facility, the hospital can electronically send pertinent information to the receiving organization via a care coordination solution. This ensures the post-acute organization has all the information it needs before the patient arrives on site. The hospital can also leverage this kind of technology to maintain communication with the post-acute provider over time, determining that the patient is being treated appropriately and is not a candidate for readmission.

When a patient is discharged home, hospitals can use care coordination solutions to manage and track a patient's health indicators, including blood pressure and pulse oximetry. Through the technology, the hospital can quickly determine which patients are following their care plans and those who might need an intervention to prevent hospital readmissions. Case managers can then focus their attention on those patients who require assistance.

Cultivating patient engagement. The patient can either be a facilitator of or a roadblock to positive outcomes. Especially for those individuals with chronic diseases, patient involvement is critical to long-term health. However, similar to fostering transparency between settings, hospitals have long wrestled with ways to engage patients and often struggle involving them in their care and its processes. No matter the patient, they all respond differently to hospital discharge. Some are eager to follow their care plans and are diligent about filling and taking prescriptions, monitoring health indicators and keeping scheduled appointments. However, others may need a little encouragement. Care coordination solutions can provide that incentive without overburdening the patient. For example, a hospital can send an individual home with a Bluetooth-enabled scale, blood pressure cuff and pulse oximetry monitor. Every time the patient uses one of these tools, the readings automatically upload to the hospital for review. If the patient skips a reading, the hospital can reach out, or if the reading reveals a concerning trend, the hospital can contact the individual to assess the need for possible further intervention.

In some cases, patients are not interested or invested in monitoring their health. To engage these types of individuals, a hospital may want to use a care coordination app that includes a patient's family members or primary care physician. When the patient skips a measurement or doesn't show up for a follow-up appointment, the hospital can contact the patient's family or doctor and ask them to encourage the patient to participate in his or her care. This social connection can be the kick start the patient needs to become more involved.

Moving in the right direction
Reaching optimal and consistent care coordination will take time; however, hospitals and health systems that use care coordination technology can dismantle the existing hurdles and take critical steps toward more collaborative care. By smoothing workflows, leveraging qualified post-acute networks, enabling transparency and fostering greater patient involvement, this technology can ensure a hospital has stronger, safer and more reliable post-discharge communication, improving the quality of patient care while reducing the risks of readmission.

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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