With reduced Medicare reimbursement a reality starting in 2012 for hospitals with higher-than-expected readmission rates, this perennial question is more pressing than ever: What can hospital discharge planners do to improve patient transitions and reduce the chance of a return visit?
Professionals at skilled-nursing facilities and rehabilitation centers clearly have a wish list of improvements in discharge practices that would benefit their patients and clinicians, suggestions that could help hospital discharge planners answer that critical question.
“First and foremost, there needs to be mutual respect between hospitals and post-acutes,” says Deborah Afasano, vice president of clinical operations for Traditions Management, a Clearwater, Fla., company that manages and consults to SNFs and other post-acute providers. “There should be a broad exchange of knowledge and expertise between the institutions. Clinicians at the post-acute want to know what the hospital has tried with the patient, what’s worked and what hasn’t.”
Start Discharge Planning Early
The top-of-mind care-transition concern of case managers and clinicians at post-acutes is that they have the patient’s up-to-the-minute clinical information, including the latest lab results, before the patient enters their facility.
Medication reconciliation and follow-up is one leading concern among post-acute clinicians. Among the many important questions that are not always addressed in the discharge summary: Did the patient miss the most recent dose of any medications due to delayed transportation? Does the patient need labs to follow up on a new medication such as a statin or an ACE inhibitor?
“The more information that we get prior to admission, the better, such as a wound requiring a special mattress, a need for oxygen or a hip chair,” says Susan Heller, PT, director of rehabilitation at the Friedwald Center for Rehabilitation & Nursing in New City, N.Y. “Some discharge planners will give this information and some won’t.”
Be Timely and Concise with Communications
Post-acute clinicians’ need for information goes well beyond the patient’s record of illness and treatment. Simple notes written by the discharge planner can help bridge the communication gap. Unique aspects of each patient’s case may not seem obvious to communicate, but are helpful to case managers and nurses at SNFs and rehabs.
Does the patient understand her own illness and current medical condition? Has the patient been able to get around her hospital room safely? Does she need an interpreter? If the patient desires the continued involvement of her primary care physician, has that doctor been kept in the loop with the discharge summary, etc.? Did the patient or her family resist the post-acute placement, and if so, why? Does the patient have a history of non-compliance?
“Post-acute facilities need to know about risk factors such as falls, poor appetite, wandering risk and other safety concerns,” says Afasano.
Discharge planners – and, equally, their colleagues in post-acute care – will effect better care transitions if they forge strong communication bonds with their fellow institutions.
Focus on the Match
Making the best match possible should always be a best practice and is the crux of a successful placement. Focusing on identifying the correct level of care and available services, as examples, will help ensure a good match.
But according to Gene Gantt, RRT, chair of the Long-Term Care Specialty Section of the American Association for Respiratory Care, hospital discharge planners don’t always acknowledge potential mismatches between patients’ basic medical needs and the capabilities of the post-acute facility where they are being transferred.
“Discharge planners need to be knowledgeable about the post-acute facility before they send patients,” says Gantt. “Not all nursing homes have 24-hour respiratory therapists. Often BiPAP in a nursing home is a home unit with no alarms; it’s not a hospital ventilator. Discharge planners should ask the facility what level of ventilator they have.”
If the match to next level of care is not correct, this often leads to failed transitions and hospital readmissions, according to Gantt. “Discharge planners need to give exact information about the patient without sugarcoating anything, so the transfer isn’t bungled,” he says. For example, the severity of bed sores is often downplayed, sometimes leaving the patient in a SNF that is not equipped to treat the wounds properly.
Be Realistic About the Potential for Rehabilitation
Eager to give their ill or injured loved ones a chance to resume a relatively normal life, families need clear information from hospital discharge planners to guide the patient onto a realistic path toward rehabilitation. But there are a number of prerequisites to successful rehabilitation that the discharge planner must look out for.
“We assume there’s some level of the patient’s readiness to learn,” says Terry Chase, director of education for inpatients at Craig Hospital, a rehabilitation center in Englewood, Colo. “And patients have to be ready for three to eight hours a day of activity therapy, exercise classes and group programs.” If patients’ pain cannot be sufficiently managed, for example, a rehab may not be the appropriate next level of care.
Rehabilitation professionals also worry that hospital discharge planners set unrealistic expectations. “Some acute-care hospitals say, ‘You’re going to go to Craig Hospital and get cured.’ But the truth is that not all of the patient’s problems will necessarily go away,” says Chase.
John Rossheim is a writer and editor who covers information technology, careers and other topics in health care. This article reprinted with permission from Curaspan. See the original article on the Curaspan site. Or visit the main Curaspan site here.
Ed. Note: Learn more about best practices in discharge planning during the Case In Point Webinar: Securing Care Transitions to Prevent Avoidable Readmissions.