When patients are discharged, they essentially become their own care coordinator—administering medication and scheduling follow-up visits. Providers can significantly improve patient engagement and outcomes by taking advantage of outside care partnerships to help coordinate care across provider and technical networks.
For many hospital and health systems, the penalties associated with 30-day readmissions are a constant concern. Patient engagement is a critical component to enticing patients to take a proactive role in their own care. How can providers help patients realize this power and make a difference in care outcomes? The short answer is working with care-provider partners to develop a care plan that lives outside the walls of the facility—it goes home with the patient and stays with them long after they are discharged. By leveraging outside care partnerships in both a professional and technical sense, hospitals can better ensure patients adhere to post-discharge care plans.
Engaging the primary-care physician, nursing home, visiting nurse or other professional who has proximity and patient respect is essential to care plan adherence. This type of outreach doesn't necessarily require an accountable care organization. As more electronic health records are implemented and advanced meaningful use is achieved, the ability to exchange and share care plans with other professionals becomes more achievable. Engaging colleagues across the care community also might increase patient compliance more cost effectively.
Collaborating with those outside the network does not come with the barriers that many believe. If finding and connecting to the primary-care physician creates additional challenges and if the patient is insured, work with the health plan to identify the physician and make a connection. Partnerships both in and outside the ACO have great potential to engage patients and thereby improve care.
Technology is essential to realizing partnerships at scale, especially when time is crucial. Calling one patient after discharge is feasible, but building a call center to follow up with every patient is likely cost prohibitive. What providers need is near real-time exchange of information in an electronic or human readable format. HL7 formats are the obvious choice—HL7 is an international organization that has built standard formats for common clinical documents such as continuity of care documents (CCD) that describe an encounter (patient visit) and Admission, Discharge, Transfer documents (ADT) that record critical events related to patient activity at a hospital. HL7 is a native communication protocol (supported by every vendor, although there are variations) for EHRs and HL7 that can be shared in batch and in real-time exchanges. HL7 ADT with discharge instructions (a module contained within an ADT message) should be a priority in all partnership plans. If interoperability remains a barrier, consider the use of an integration hub outside of an EHR.
Integration hubs, or gateways, deliver format conversions, understand multiple protocols and can deliver secure transmissions much faster and cheaper than configurable point-to-point interfaces through an EHR. Using an integration hub can reduce the costs of clearinghouses and enable clinical exchange with those care providers outside of the network and those using a different EHR vendor.
The solution is thinking beyond the four walls of the facility and finding mechanisms to engage and build partnerships for care that reach those at risk. Everyone will benefit—and can we really afford to wait?
Ruby Raley is vice president of product strategy at Edifecs, a healthcare information technology firm.
