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Post Acute care: Care coordination technology and discharge planning are essential


The Affordable Care Act has migrated risk for the discharge process from payers to providers, making effective discharge planning essential.

Until recently, hospitals have not been accountable for coordinating patient care following discharge; that responsibility has traditionally fallen to other providers. But the Affordable Care Act has changed the game, migrating risk from payers to providers and requiring hospitals to focus their attention on what happens to patients during post-acute care. As a result, effective care coordination and discharge planning are essential for navigating and easing transitions, and ultimately improving payers’ bottom lines.

Enhance care coordination

Having skilled discharge planners or care managers on staff is vital to coordinate and facilitate post-acute care transitions properly, particularly for high-risk, high-criticality patients. Care or services can include a number of medical and nonmedical providers and include:

  •     Rehabilitation hospitals;

  •     Long-term care facilities;

  •     Home care organizations;

  •     Hospice;

  •     Outpatient services such as physical or occupational therapy;

  •     Transportation companies;

  •     Grocery or meal delivery services; and

  •     Cleaning and laundry services.

However, discharge staff are often overburdened by having to manually plan and coordinate every patient transition regardless of their risk potential or criticality.

By pairing staff with care coordination technology, hospitals can better prepare, plan and streamline patient discharges to:

Focus resources more effectively
Healthcare information technology solutions such as web-based automated transition software are intended to make processes more efficient, thus allowing hospitals to focus their human resources more effectively when personal interventions are truly needed.

Engage family at admission
Family engagement is important to achieving better patient outcomes. Based on the geometric mean length of stay for specific diagnoses, hospitals know approximately when patients will be discharged and can use this information to begin planning the patient’s discharge with the family as early as the time of admission. When integrated with care coordination technology, portal and mobile technology can also be leveraged to empower families to communicate with providers.

Facilitate, automate discharge process
Using IT-enabled solutions instead of manual processes can enable hospitals to extract and automatically send discharge information to a receiving provider. Hospitals can also expedite the discharge process with technology by receiving responses from post-acute providers in as little as 30 minutes rather than days. This can be especially beneficial for hard-to-place patients.

Eliminate workarounds
Some hospitals have resorted to placing patients under “observation status” for hours rather than admitting them in order to avoid penalties associated with readmissions and other quality measures. Eliminate this workaround by using coordination technology and analytics to stratify the patient’s risk for readmission. 

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