Lay the groundwork for bundled payment; here are three areas in which technology can play a role.
As organizations embrace value-based care, they are beginning to appreciate the importance of robust care coordination. The more providers collaborate and communicate, the more likely patients are to receive appropriate, non-duplicative and timely interventions, which can mitigate risk, reduce costs and yield better patient outcomes.
Coordinating care is especially critical now that hospitals are required to comply with the Centers for Medicare & Medicaid Services (CMS) bundled payment initiatives-specifically, the Comprehensive Care for Joint Replacement (CJR) model and the cardiac care model. These programs point to the need for a broad healthcare team that should include the hospital, the patient and family and any post-acute providers, with the hospital at the center, assuming the majority of risk for the quality and cost of care. Since these initiatives represent the first of many similar risk-based models, it is clear organizations no longer have a choice as to whether to coordinate care across settings-it is becoming a necessity for long-term viability.
However, the fundamental challenge with care coordination is that hospitals and other providers are not accustomed to or equipped for working together, and the infrastructure to support information sharing, care planning and patient monitoring simply is not present in many organizations. Yet, this is starting to change as hospitals and other providers seek effective methods for reaching patients beyond their walls.
One approach gaining favor is the implementation of care coordination technology to guide patient transitions.
Here are three areas in which this kind of technology can play a role.
When patients are ready to leave the hospital, they often require the services of a post-acute organization, such as a skilled nursing facility or rehabilitation center. Deciding where to go next can be a daunting proposition for patients and families who are not familiar with the different options. Hospitals can assist by giving individuals the information they need to make informed decisions. Not only does this improve patient satisfaction, it can lead to better clinical outcomes because the hospital can recommend post-acute providers that are fully qualified to deliver optimal care.
Care coordination technology can help hospitals guide patients to the most qualified providers. Once a case manager inputs key patient information, including his or her clinical needs and personal preferences, the software produces a well-vetted list of potential providers that best meet the patient’s requirements. The case manager can then quickly determine which of these facilities is able to accept the patient, matching pre-generated provider profiles to the patient’s needs, which the care planner shares with patients and their families. Patients can view and compare facility profiles, scanning through images, videos and testimonials and if they have specific questions for a post-acute provider, they can even message the facility within the software tool. Once patients and their families review the information, they are able to rank their top choices, which are recorded for regulatory purposes. This not only ensures patients make more educated decisions and feel engaged in the process of their next care stage, but also enables the hospital to document the process, thus leading to a smoother, more successful transition.
Healthy collaboration stems from smooth information exchange. Organizations can use care coordination technology to share information directly through the electronic health record (EHR). With a click of a button, hospitals can send key portions of the patient’s medical record in an easily digestible format to post-acute providers, giving them quick access to relevant and timely information. This allows them to better plan for the patient’s care and avoid missing therapies or medications, supporting greater continuity during the transition process.
The days following a hospital discharge can be challenging for many patients as their health and risk for readmission fluctuates depending on whether they follow treatment plans, receive the appropriate therapies or respond to interventions as anticipated. During this sensitive period, it is extremely important that providers keep in touch with one another, as well as with the patient. With this in mind, organizations are beginning to leverage configurable communication apps that unite all members of a patient's care team, including primary care physicians, hospital case managers, home health nurses, pharmacies and family members. Through a single-source electronic command center found in these solutions, team members are able to virtually “talk” about the care plan, closely monitor the patient's path after discharge and receive real-time updates as the patient’s needs change. The solution can even deliver alerts to relevant care team members when interventions or escalations are warranted.
By better matching patients with post-acute providers, improving information exchange and facilitating greater communication across settings, organizations can demonstrate value-based, effective and efficient care. For example, by matching patients with providers that can fully meet their needs, organizations can ensure patients receive timely and comprehensive care, increasing the likelihood of positive clinical outcomes and limiting the chances of unplanned readmissions. Furthermore, when hospitals and post-acute providers proactively share detailed information about the patient’s care, they can prevent duplication of services and unnecessary tests while also reducing gaps or omissions in care. Ultimately, these actions decrease the cost of care while maintaining or even improving quality-the fundamental tenets of value-based initiatives.
For most organizations, the ability to synchronize care across settings is a work in progress, but as bundled payment models take center stage, organizations have to increase their commitment to cross-continuum collaboration. By embracing care coordination solutions that bolster communication and teamwork, hospitals can gain needed insight into a patient’s post-discharge care, treatment and current health, taking the next step to further value-based care.
Luis Castillo is president and CEO of Ensocare.