To optimize patient outcomes during care transitions, healthcare providers must integrate discharge planning across the entirety of the care continuum. Successful discharge planning should start at admission, as this is a continuous process. When providers prioritize the critical components of discharge planning throughout the course of inpatient treatment, adequate resources can be identified to better support the patient upon discharge. By utilizing technology, healthcare organizations can develop data-driven structures to enhance the discharge process and ultimately, improve the patient experience.
Establish and Maintain an Organizational Culture of Safety and Improvement
At the University of Alabama at Birmingham (UAB) Health System, innovation in care delivery is a key organizational priority. As a national leader in clinical care, biomedical research, and medical education, UAB is advancing healthcare by developing innovative care management models that change countless lives. Implementing a culture of safety and coordination has allowed the system to rapidly deploy processes that improve patient care inside and outside of their facility.
John Dodd, Program Manager of Patient Experience and Engagement at UAB, shares the importance of implementing the right processes and technologies to drive success. Dodd also emphasizes the significance of generating buy-in and creating a culture of excellence across the organization.
At UAB, digital rounding technology is leveraged as a vehicle to achieve patient experience goals while supporting effective discharge planning. Digital rounding technology empowers employees at all levels and functions of the organization to ensure the safety and quality of care throughout the patient's stay. CipherHealth's integrated patient engagement platform helps healthcare providers at UAB gain visibility into issue resolution, quality improvement initiatives, and staff workflow - which informs opportunities to improve care delivery. UAB has expanded the scope of rounding and care transition initiatives to advance quality improvement throughout the entirety of the care continuum.
Create Rounding Processes that Drive Improvements
One example of this is UAB's daily multidisciplinary rounds, also known as “Transitions of Care” rounds, to improve the quality, safety, and patient experience of care. Dodd explains, “By collaborating and coordinating care delivery among all those involved in the plan of care, the team is redesigning healthcare to meet patients and family members where they are.”
Every morning, UAB brings nurses, physicians, social workers, care coordinators, and other members of the healthcare team together on every inpatient unit to discuss the plan of care for every admitted patient. By integrating care transition considerations - such as the patient's daily goals, treatment response, and barriers to discharge - into the “Transitions of Care” rounds, the UAB care team proactively anticipates and addresses patient concerns for enhanced discharge planning.
Going one step further, care coordinators at UAB utilize Orchid to audit “Transition of Care” rounds to ensure rounding activity across the hospital is consistent across inpatient units and patient populations. The “Transitions of Care” audit is just one of more than fifty use cases that UAB has developed with their digital rounding technology. Dodd explains, “Proactively identifying issues or concerns optimizes care delivery by shortening length of stay and ensuring that patients can safely transition out of the facility upon discharge. The added value comes by tracking these events over time to drive process improvements that can prevent future errors.” By leveraging one platform to collect data from multiple sources, these processes drive accountability across teams with rounding-specific process metrics and outcomes measurement.
“The rounding initiatives foster a culture of trust so people feel comfortable bringing their concerns to leadership,” Dodd shares. In particular is UAB's Patient Safety Leadership Rounding program, in which the executive nursing team goes to units and rounds on employees to encourage them to share “near misses” - for example, a patient almost receiving the wrong dose of medication. This initiative is a key component of building a culture that seeks to celebrate, rather than criticize, staff who report “near misses”.
Empower Patients with the Right Information at the Right Time
Since discharge planning involves the transfer of information from the provider to the patient, this is an often-overlooked opportunity to empower patients in becoming more active participants in their healthcare. To improve post-discharge patient outcomes, clinicians can provide patients with the tools they need to successfully manage their plan of care during these care transitions.
UAB improves patient comprehension of and adherence to the plan of care with recorded personalized discharge instructions. To identify the most important information to provide patients during discharge meetings, UAB nurse leaders collaborated with providers in outpatient clinics to understand the challenges and symptom(s) that patients commonly experience in their follow-up appointments. “With this data, nurse leaders tailored their discharge instructions and plan of care based on adverse events that patients frequently encounter at the next setting along the care continuum - developing best practices for safer discharge planning,” Dodd explains.
The UAB team empowers patients to access their discharge conversations at home with recorded care instructions - leading to positive results in readmissions, no-show rates for follow-up appointments, and HCAHPS scores. Due to these initial successes on two units, UAB is expanding the use of this technology throughout the organization.
When healthcare organizations proactively prioritize discharge planning, patients receive the support they need to better manage their post-discharge plan of care. With technology that identifies issues and personalizes the patient experience, healthcare organizations can streamline care processes to improve the quality of care delivery throughout the patient journey and ensure optimal post-discharge patient outcomes.
