For patients, every transition of care to a different facility brings the risk of complications.
When a patient is transitioning from a hospital to a post-acute care facility, for example, essential patient information relating to medical history and medication lists may be lost, overlooked, or not shared, resulting in delays to treatment and suboptimal care.
Like many things in life, successful transitions of care often start with strong communication. To match patients to the most appropriate facilities for their conditions, hospital case managers must have efficient processes to identify the right post-acute partner for transition and to understand whether that partner has capacity now.
However, workers on both the providing and receiving ends of patient transfers are often overburdened with administrative processes and technological inefficiencies that bog them down and prevent them from doing higher-value clinical work. For example, a hospital case manager may have to send faxes and make phone calls to multiple skilled nursing facilities (SNFs) within the hospital’s network to identify which facility is most prepared to accept a given patient.
To overcome these limitations associated with post-acute patient transfers, many providers are adopting post-acute placement technology grounded in best practices and surrounded by a network of engaged providers. By streamlining many of the basic processes associated with transitions of care, these solutions enable health systems to enhance patient flow and throughput, improving the patient experience, reducing wait times, and enabling valuable and scarce clinical workers to operate at the tops of their licenses.
Why discharge planning needs improvement
Numerous inefficiencies exist that can disrupt the hospital discharge process, such as challenges matching patients to the right levels of service, staffing shortages, and issues with patients’ insurance. When these problems arise, they can result in patient stays that are longer than necessary, a costly problem for hospitals. For example, reducing avoidable days saves providers over $3,000 per day for each patient while making more capacity available for waiting patients in the ED, PACU, or at a facility needing a higher level of care transfer.
Discharge to SNF, the most common post-acute referral, is a frequently inefficient process that results in hours or days of delays. Many of these issues stem from poor orchestration between care teams and a lack of standardized patient transition processes and workflows. Common causes of delays include issues with insurance authorization, SNF approval response time, engaging appropriate care providers, timeliness of recognizing the need for SNF and initiating the process, and arranging transportation.
In addition to improved communication between referring and accepting facilities, the increased efficiency delivered by referral and placement technology frees bedside workers to focus more time and attention on patient care and communication. That is significant, because improved discharge communication drives better patient outcomes, according to a 2021 review and meta-analysis published in JAMA Open Network.
Indeed, the review revealed that communication interventions at discharge were significantly associated with lower readmission rates (9.1% vs. 13.5%), higher adherence to treatment regimen (86.1% vs. 79.0%), and higher patient satisfaction (60.9% vs. 49.5%). While discharge communication directly with the patient drives most of these success metrics, the post-acute providers must also be well-informed so they can be accountable for the delivery of intended outcomes. Thus timely communication of pertinent information must be passed from the hospital to the post-acute provider with the same intentionality as with the patient.
3 ways post-acute placement solutions improve transitions of care
While there are numerous benefits to health systems from implementing solutions that improve post-acute-care transitions, the following three stand out as the most significant:
- Reduced administrative burden – Modern technology helps hospital case managers eliminate most phone calls and faxes to post-acute providers and automates transportation coordination to drive earlier discharges. As a result, employees are liberated from mundane, repetitive tasks to function at the top of their training, boosting staff satisfaction.
- Greater operational efficiency – By gaining a system-wide picture of post-acute network performance, health systems can improve common operational processes across care management teams. Health system leaders can then use this 360-degree view of network performance to drive more productive conversations with post-acute providers and ultimately improve the curation of their networks, leading to an efficient high performing network that are true partners of the health system.
- Better patient care – With earlier initiation of the post-acute placement process, health systems accelerate the timeline for discharge, enabling patients to get the care and treatment they need more quickly in the appropriate setting. With more efficient, effective, and comprehensive communication between hospital case managers and post-acute care representatives, patient transitions are more likely to be successful allowing patients to return to their communities.
In the past, care transitions have often come with concerns about risk and uncertainty. Still, many health systems are implementing post-acute placement best practices and technology to improve the process. By reducing administrative burden and driving greater operational efficiency the patient flow of the post-acute placement results in better experiences for patients, providers, and staff.
About Lane Wise
Lane Wise joined ABOUT Healthcare in 2019 as Director of Customer Success bringing with him over 20 years of clinical experience in healthcare operations and patient care. Lane is a proven healthcare leader and has successfully delivered clinical consulting and ongoing improvement initiatives with customers. Before joining ABOUT Healthcare, Lane was Director of Patient Navigation at PHI Health. Prior to that, he held nursing leadership and paramedic positions at West Tennessee Healthcare.
