In today’s value-based environment, hospitals are under financial pressure to discharge patients sooner while ensuring patient safety and quality of care. This challenge comes with the clear risk that releasing patients too quickly can result in costly readmissions.

Discharge planning that requires care coordination is a complex process. Managing the transition from the hospital to a post-acute setting can be time consuming for discharge planners and care management staff. If prior arrangements with a particular facility are pending or have not been initiated, patient placement requires extensive communication and coordination among multiple care team members.

Considering the volume of patients released daily from a hospital, case managers often devote half their time to discharge planning. Statistics posted by the American Hospital Directory (AHD) show 31,787,121 annual discharges in the U.S. for 2017, an average of 87,088 discharges each day from U.S. hospitals. It’s no wonder the best efforts of case managers may not ensure the best post-acute option. Even with expanding EHR integration, many hospitals still rely on manual processes to manage patient care transitions.

Bloomberg photo

To achieve better discharge planning, providers are trying a range of options to increase efficiency without compromising patient care and increasing risk of readmission.

For facilities without automated solutions in place, the go-to method is clipboard, paper, phone and fax. This process entails extensive time and effort on the part of the planner to track and manage patients.

Staffing hospitals with nurse navigators is another popular approach used when the patient leaves the hospital and requires management and follow-up. This method requires highly trained clinical professionals whose only job is to contact patients continually to find out if they are following the care plan.

Some hospitals are even placing employed physicians or nurses in post-acute settings to maintain oversight of their discharged patients. Overall, these options are costly, time consuming and not sustainable in a value-based environment.

Many providers look to an EHR to do the work of discharge planning, but most aren’t equipped to handle the level of coordination needed once the patient leaves the hospital. One popular solution provides a two-way communication connection between the EMR and approved external entities—such as post-acute facilities, pharmacies, LTAC facilities and more. However, these solutions do not provide access to verified and engaged networks to help identify patient options post discharge. The lack of interoperability between the EHR and post-acute care facilities and other external resources is still problematic without a technology solution specifically designed for that work.

Given the limitations of nontechnology methods, healthcare organizations can benefit from automated discharge technology to support continuity of care. These solutions create efficiencies that decrease the time spent on manual activities. For example, a case manager can quickly enter a patient’s requirements for post-acute care, receive a list of suitable organizations, and help the patient and family members choose the best placement. Using care coordination software also helps providers avoid many of the challenges involved in care transitions such as preventing adverse events and readmissions.

As part of discharge planning, hospitals can establish a centralized process enabling all care team members to connect virtually and follow the patient’s progress. Beginning the process early in the patient encounter promotes improved clinical outcomes and patient engagement while reducing avoidable readmissions.

The value of using automated solutions to manage care coordination extends to all hospital stakeholders including C-suite leaders, clinicians, employees, patients and families. While the benefits cross boundaries, each stakeholder group stands to gain in four areas—risk mitigation, efficiency, patient outcomes and patient satisfaction. In addition, the transparency offered by systems and business processes of accessible information provides hospitals and physicians with data to benchmark performance and quality improvement efforts. At the same time, access to comprehensive information empowers providers, patients and their families to make informed post-acute care decisions.

IT executives considering technology solutions to improve discharge planning procedures should do the following.

  • Conduct an assessment of existing discharge procedures and seek ways to improve workflows around this process using existing IT resources. Examine the ways in which post-acute facilities are presented and selected for patients and make sure these processes are aligned with regulations surrounding care coordination and any new regulations that may be on the horizon.
  • Plan now to learn about HL7, FHIR and the ability to use this standardized programming language to benefit the IT processes within your organization. The first step to achieving interoperability that can extend beyond the hospital’s walls is making sure your internal hospital systems can communicate. Prepare for the many impending APIs that can benefit your organization in post-acute management.
  • Explore the automated solutions available to help your hospital manage the details around hospital discharge and post-acute management. Clerical hours saved can be transferred to personalized patient care to those who need it most—the chronically ill or those with complex medical conditions. For steps that can be automated, let technology do the work. This leaves more time for clinical staff to work top of license, improving patient satisfaction and outcomes.

Implementing technology can provide important side benefits. For example, hospitals making the transition from a manual to an automated discharge process can see length of stay (LOS) reductions of up to one full day for patients moving into post-acute facilities. This outcome supports enhanced revenue since a vast majority of reimbursement, especially Medicare, is set by diagnosis.

Automated discharge technology offers a cost-effective, scalable and sustainable option for mitigating risk inherent in managing care transitions—readmissions, extended LOS, inappropriate post-acute placements, operating costs associated with avoidable delays and other inefficiencies. Providers experience greater opportunities to expedite care transitions, improve outcomes and contribute to patient and family satisfaction. Moreover, the potential benefits are essential to achieving value-based care initiatives.

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