Care coordination and technology: The keys to improving post-discharge care

This content is sponsored by CipherHealth.

Improving post-discharge care has become a growing source of interest and exploration as hospitals put a stronger emphasis on reducing readmissions.

The shift from a fee-for-service model to a pay-for-performance model of care has thrust readmissions into the spotlight as a major indicator of hospital performance. Medicare's decision to tie hospitals' reimbursements to readmissions upped the ante further.

For Zach Silverzweig, co-founder of the healthcare solutions company CipherHealth, improving post-discharge care isn't just about good business, it's personal.

Mr. Silverzweig is a cancer survivor who — roughly 10 years ago — was treated at one of the top hospitals in New York City. Despite the hospital's prestige, the care Mr. Silverzweig received after being discharged left quite a bit to be desired.

"The amount of support I got once I left the four walls of the hospital is night-and-day different than the kind of experience that I see becoming more standard nowadays," says Mr. Silverzweig. "I remember creating a spreadsheet with medication guidelines for myself because it was before many EMRs printed discharge instructions. I also don't believe I received any follow-up calls or contact from my doctor, with the exception of my scheduled follow-up appointments."

Mr. Silverzweig isn't alone; poor care coordination and post-discharge practices leave patients feeling confused and frustrated, decreasing the likelihood that they'll adhere to medication and discharge instructions and increasing the likelihood of an unplanned readmission.

Tackling the source of the problem

Mr. Silverzweig knows firsthand the impact post-discharge care (or lack thereof) can have on making the transition from the hospital to home easier and avoiding unplanned readmissions.

That said, preventing unplanned readmissions means hospitals must first tackle the crux of the problem, namely identifying what causes patients to make unplanned trips back to the hospital after being discharged. All too often, the reasons are relatively small issues that could have been prevented if they were addressed earlier with a simple phone call.

"The issues we see patients having the most trouble with are usually pretty simple," said Mr. Silverzweig. "For example, we look at whether the patient understands their discharge instructions, whether they are able to get and take their medication, and whether they have a follow-up appointment."

Some hospitals have found automating their follow-up phone calls has helped identify patients who are at risk of being readmitted to the hospital, connect patients to the appropriate channels of care, improve patient satisfaction and avoid unplanned trips back to the emergency department.

For instance, the Voice tool from CipherHealth reaches out to patients after they have been discharged to identify individuals with satisfaction or clinical concerns. Patients that report having an issue are then put in touch with the hospital staff who can address the problem.

According to CipherHealth, hospitals that have employed Voice have seen considerable success with increasing satisfaction, improving workflow and reducing readmissions with the program.   

In addition to the three core patient challenges — discharge instructions, medication adherence and follow-up care — many hospitals rely too heavily on risk stratification tools to predict patient outcomes, according to Mr. Silverzweig.

While risk stratification tools can be useful, there is no replacement for direct communication with patients about their wellbeing after returning home from a hospital visit. Asking direct questions about their recovery and assessing progress through their care plans is the best way to determine if a patient requires intervention, he says.

How care coordination can prevent unplanned readmissions

Often times, frontline healthcare workers are the greatest tool hospitals have to improve post-discharge care and prevent readmissions.

"Care coordination is all about connecting the dots," said Mr. Silverzweig. "It's about giving the care team the right information at the right time. For instance, once piece of information about a patient in different people's hands can be the difference between an unplanned readmission or simply a phone call or consultation."

From the early adopters to the hospitals that have just recently jumped on the post-discharge wagon, the methods for coordinating care are almost as diverse as the patients themselves.

Some hospitals and healthcare facilities utilize clinical call centers to follow up with patients after they've been discharged while other hospitals assign the responsibility to individual nurse managers, care coordinators or — in the cases of more specific cohorts and patient populations — health coaches.

Leveraging technology as a post-discharge care tool

In addition to having workers take accountability for following up with patients, hospitals can utilize tools that, while relatively simple in their concept, can make a world of difference to both patients and their loved ones.

Addressing issues such as misunderstanding discharge and medication instructions may be as providing patients with easy access to the instructions after they've returned home.

Another tool CipherHealth created, called Echo, does just that. Echo allows clinicians to record important medication or care instructions during the discharge process with a patient. The recordings can then be played back to the patient during their Voice call or when a patient calls in on their own to hear their Echo.

By recording discharge instructions, hospitals have seen higher engagement rates with Voice post-discharge, as well as, increased understanding about medication and discharge instructions in general.

Patients can also play recorded discharge instructions and information for family members, caretakers and loved ones, putting their minds at ease, according to CipherHealth Vice President of Marketing Katharine Walker.

For many hospitals that have taken the steps to improve care coordination and have implemented post-discharge technology tools, the results have been practically instantaneous, according to Mr. Silverzweig.

"At some level, there is an immediate benefit and cultural change that is apparent after implementing this system," said Mr. Silverzweig. "The stories we get about patients that were likely going to be readmitted but, because of a post-discharge tool, were saved or were connected with an appropriate avenue for care, start to come up in the first days or weeks after implementation."


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