A Change in Culture to Improve Discharges

by Marianne Ramey, Senior Partner, PhoenixMed
Published on Jun 23, 2015

Healthcare reform continues to pick up steam.  The changes in reimbursement and the introduction of new incentives bring continued uncertainty and anxiety for healthcare providers, patient and families, and healthcare leaders. Everyone hears that the changes are meant to bring about high quality care at the lowest price.  But the question on the minds of everyone is how will this be accomplished?

As read in the magazines and journals and heard at healthcare conferences, many terms and buzz words are being bandied about to describe the changing landscape such as continuum of care, care coordination, collaborative care, transitional care, and value based care.  But to most of us, the bottom line is how to provide efficient, timely, high quality care which protect patients from clinical harm and financial risk, and decreases providers' liability against the readmission penalties.  One of the major challenges is to identify and implement systems to optimize patient care transitions. A change in culture is needed to have a successful transition program.

Change The Words and Change the Conversation

Traditionally, we think of hospital care as a single episode of care beginning at admission and ending at discharge.  In considering the future, leaders must help providers think in terms of the care continuum. Typically, a nurse identifies a patient's preliminary discharge plan.  S/he may refer the patient to a care manager if the post acute plan is fraught with complexities or s/he may confirm the plan with the family and healthcare team and refer the arrangements to a support team schooled in finding resources and facilitating the arrangements. In addition, the nurse provides the patient and family with instructions, a list of current medications and the timeframe for follow-up care.  In many instances there is little or no verification of the patient's understanding and commitment to future care requirements.  Active patient participation in the transition process requires a conversation, not just one way, and should take place as the day of discharge nears. Patients and families should be asked to actively participate in decision about follow-up care and their ability to participate. They too must understand that their stay in the hospitals is just one piece of their care continuum needs. 

Case Managers and the High-Risk Patient Population

The focus of any redesign of the transition process should be to safely move patients out of the hospital to the next site of care, whether that means returning home with or without home care,or transferring to a SNF or rehab facility. It must  be done in a way that prevents unnecessary readmissions and adverse events.  An important factor is to identify high-risk patients and begin the transition process as soon as they are admitted. This is where a case manager excels but without knowledge of the high risk patients the case manager is at a disadvantage.  In highly technologically savvy hospitals, predictive analytics can identify high risk patients within 24 hours of admission based on data regarding how many previous admissions, recent visits to the ED, polypharmacy and/or category of current drugs, comorbidities, age, and social situation. For less savvy hospitals, the method of identifying these patients usually involves the initial patient assessment which captures many of these predictive variables and results in a direct referral to a case manager.  With their focus on the high risk patients, the case manager can give these patients special attention while the clinical nurse processes the more 'routine' discharge of the other patients.  

No matter what strategies are used or how they are applied, it is irrefutable that the constantly changing marketplace requires each facility to take a second, third or fourth look at the patient transition process and make sure that every member of the patient's care team understands and accepts their role in making the transition safe, timely and effective.