New people, new tools needed for effective post-discharge monitoring

It seems like a no brainer. Hospitals need new ways to engage and monitor patients after a stay because they face financial penalties for excess readmissions within 30 days after discharge.

Yet it's often far down on their to-do list.

The readmissions penalties have driven many hospitals to mine their data and work more closely with the post-acute care providers like skilled nursing facilities, rehabilitation hospitals and home healthcare agencies who care for their patients after discharge. This often means putting in place new computer systems and procedures.

Monitoring and engaging patients post discharge is the obvious next step, especially now that bundled payments covering up to 90 days after discharge are being implemented for a number of orthopedic and cardiac procedures. But to do this effectively, an infrastructure needs to be put in place.

Often when hospitals look to identify approaches to improving care coordination across the post-discharge continuum of care, they begin by assessing their own capabilities. Then it becomes a matter of identifying key touch points or transitions (think: moving into and out of the hospital) where engaging and monitoring patients can drastically improve the overall quality of care.

“When we look at deploying (new) technology to our patients, we look not only on the level of applicability to a specific patient, (but also) look at the organizational readiness to effectively manage a new, and often complicated, stream of data,” said Matthew Fenty, Director, Innovation & Strategic Partnerships at St. Luke's University Health Network in Bethlehem, Pa.

Post-discharge care is a timely topic. This year the CMS mandated almost 800 hospitals throughout the country participate in the Comprehensive Care for Joint Replacement Model, making them responsible for patients' clinical and financial outcome 90 days after being discharged for a hip or knee replacement. Three months later CMS issued another directive, the Cardiac Rehabilitation Incentive Payment Model, requiring hospitals to do the same for Medicare beneficiaries with heart attacks, coronary bypasses, and hip and femur fractures.

Participating in these programs means sharing more information with physicians and post-acute care providers. To do this hospitals have updated their electronic medical records systems or bolted on entirely new systems. They are also developing common surgical and discharge protocols. Given the enormity of the task, many hospital administrators are wary of adding another product to the mix.

“We are focused on low-hanging fruit,” said Roy Schwartz, vice president of managed care and payer relations at Penn Medicine. Post-acute care can run up “half the price (of an episode of care) and almost 100% variability.” Penn is working with an outside vendor to get its geographically disparate network of post-acute care providers up and running on a common technology platform that shares patient information among providers. The system operates outside Penn Medicines electronic health records.

Healthcare systems also need to identify patients, who qualify for one of Medicare's new episodic programs. This is easy if someone is admitted for a scheduled surgery, but more difficult for patients who are admitted through the emergency room.

“If someone comes to emergency department with shortness of breath, it could be COPD, pneumonia, heart failure or influenza,” she Dr. Zenobia Brown, a medical director at NorthWell Care Solutions, in Great Neck, N.Y., adding that a hospital “could lose days waiting for the DRG to drop.” (A DRG is the diagnostic code that hospitals use for billing under fee-for-service payment; each bundle is comprised of a number of DRGs.) By that time a patient could be discharge or miss critical post-acute care guidance.

To find these patients, NorthWell created what it calls Care Tool, a platform designed for providers that coalesces information from multiple systems for each patient: the admission, surgical scheduling, electronic medical records, and (within the next year) pharmaceutical data. The technology also allows doctors and nurses to track a patients through different post-acute care facilities or even if they show up in emergency room of another hospital in the region.

Determining whether an organization is ready to begin coordinating care among outside providers goes beyond computing. Eliciting electronic feedback or data from patients requires having someone able to monitor and act on the information.

And that, in turn, requires designating a point person at every hospital within an organization, which may not be possible due to cost or other constraints. Northwestern Memorial HealthCare, for example, has seven hospitals. Its downtown Chicago hospital, Northwestern Memorial Hospital, is experimenting with one technology that monitors and engages patients and works optimally with a first responder or care navigator.

But other hospitals in its system don't have care navigators. “The landscape of solutions is fragmented,” said Dr. Hannah Alphs Jackson, program director of value-based delivery, Northwestern Memorial HealthCare.

While hospitals may have initially looked inwards assessing their own operations, they are now beginning to look for ways to foster electronic communication between patients and providers during the post-discharge period. The key is assuring that patients know how to use and will benefit from any new technology.

Fenty of St. Luke's in Bethlehem, Pa., considers factors like: patents' technological sophistication, ability to understand discharge plans or make clinical decision and overall desire to use the technology.

It needs to be intuitive and easy to access without a patient having to enter too much information to log on, Brown said. “Anything that takes too much time won't work in healthcare,” she said.

Having technology that captures the entire episode of care is also a key consideration. For scheduled surgeries, like hip and joint replacements, hospitals can begin to engage and monitor patients before they set foot in the hospital.

Electronic communication can reinforce physician's surgical instructions, reminding patients to stop taking blood thinners or encouraging them to clean their home to minimize the risk of falls. Ideally the technological solutions also enable patients to ask questions without picking up the phone or going to the doctor's office.

Medical practitioners are increasingly acknowledging that hospital stays induce stress and creates almost a disease-like state. Patients are awoken at odd hours; witness trauma; and lack a predictable routine. In this state it is hard to understand discharge instructions, said Dr. Kumar Dharmarajan, an assistant professor at Yale School of Medicine, adding that patients rarely recover from the stress immediately after discharge.

But electronic communication to patients once they've returned home can reinforce discharge instructions by breaking it down into smaller pieces and addressing fears and anxiety, ideally in real time. “It's about removing the mystery,” Dave Stenerson, CFO, OSF Healthcare, Peoria, Ill.

In part three, read about the new emphasis on social factors to reduce readmissions.

Lisa Ward is a freelance writer based in Mendham, N.J.