Planning The Next Site Of Care as the First Priority

When was the last time you heard about a patient whose goal was to stay in the hospital longer than necessary and return to the hospital as soon as possible? Discharge delays don’t arise from a desire to stay, and readmissions are rarely voluntary or planned, yet, both are caused often by confusion, concerns, and barriers related to when, how, and where the patient receives care next.

It’s critical to start the hospital stay by keeping our patients’ best interests and goals for discharge at the top of the list of priorities. Aligning patients, their families, the hospital, and physicians toward the goal of discharge to the right setting without unnecessary delays is key to delivering better care – and a better experience for the patient – at a lower cost.  It’s just the right thing to do.

However, achieving a timely transition of care while simultaneously lowering the risk of readmission remains one of the toughest challenges in the quest for value-based outcomes. It requires clear, proactive communication and alignment among all who are involved in the acute “episode of care” – from the first day of an inpatient admission through the entire post-acute period.  It’s important to note that during this episode, on average, 38% of spending is related to skilled nursing facility utilization and readmissions. At the start, the hospitalist is positioned to lead the conversation and plan for a transition to the appropriate next site of care. The hospitalist keeps everyone on the same page and sets consistent expectations versus varied (and sometimes conflicting) perceptions among patients and their families.

Importantly, hospitalists planning for the entire episode of care enables the primary care physician to see the benefits of what occurred in the hospital and supports them as they take over seamless management of their patient back in the community setting. 

A Model for Successful Transition of Care

Engaged Hospitalists

Success depends on engaged hospitalists who build trust with patients and families, and alignment with specialists, primary care physicians, as well as inpatient and outpatient facilities to achieve the best clinical outcome for that patient in a value-focused way.

Keeping physicians engaged depends upon aligning care models and reimbursement incentives in support of what is in the best interests of the patient, rather than in support of the number of patients or procedures. Hospitalists need time to participate in multidisciplinary rounds and care team huddles, proactively plan the transition with the care management team.

At the time of discharge, they need time to address questions and clearly document and create holistic plans of care. They can clarify how medications may have changed and anticipated other factors that may impact the patient post-discharge.  Finally, they need time for a considered handoff of clinical care to the next provider and/or PCP or specialist.

Resources and Technology

Clinically validated best practices that focus on the whole patient in a value-based approach are needed to support physician decision-making in real-time.  Clinical processes embedded in a physicians’ daily technology workflow can ensure consistency and efficiency in doing the right thing for patients. But to be clear: technology must make it easy to do the right things, as opposed to making it more complicated or more time-consuming.

Removing barriers and investing in the right type of technology and resources are vital to keeping physicians engaged. Patient-centered, technology-enabled, physician-led workflows have resulted in significant improvement in clinical outcomes, greater patient satisfaction, and, ultimately, significant cost reductions.

Sound Physicians’ proprietary technology platform, SoundConnect, was built specifically to be put in the hands of our clinicians. From the point of admission, SoundConnect prompts clinicians to start advanced care planning and goals of care conversations. This empowers our clinicians to be proactive in making next-site-of-care decisions and helps to optimize the use of high-quality networks. Furthermore, SoundConnect allows for communication with patients’ primary care providers to ensure continuity of care.

High-Quality Networks

Too often, discharge destination decisions are reactive, based on the availability of beds or subject to referral patterns that may not be grounded in value or measurable outcomes.  Overcoming this requires established relationships with a network of high-quality post-acute providers, facilities, and home health resources in the community. It is important to follow a transparent and rigorous process for evaluating facilities and then working collaboratively with them to plan for each patient’s transition and treatment.

Starting with the End in Mind

When the hospitalist team “starts with the end in mind,” the path from admission to transition consistently leads to shorter stays and fewer unnecessary readmissions. Instead of frustration and confusion, the journey produces greater satisfaction for our patients, their family, and the primary care physician. As this model continuously improves, we see that the approach that works at the individual level translates to positive outcomes for an entire population.