Last fall, a study by Healthcentric Advisors found that monitoring hospital staff adherence to standardized communications with a patient’s primary care provider and providing feedback to staff had a positive impact on care transitions and readmissions. Although the study focused on the care transition process with primary care providers, the findings also hold true for hospitals. The two biggest points that stood out were transparency and standardization – but how do you measure their practice?
Transparency
That need for transparency in transitions of care is not a great revelation. The big question is how to implement transparency in a hospital? It’s critical for hospitals to be able to see all messages, referrals sent, viewed or declined, and if a provider has not responded. The hospital also needs to know which providers can meet the patients’ clinical needs in their location. Furthermore, the case manager needs real-time feedback on what has actually been done and what is still outstanding.
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Standardization
Another interesting point from the study was how much process variation there was across staff members, and how surprised participants were to learn that it existed. During implementation workflow analysis, we often note variation not only among staff, but also among different facilities in the same system. In order to achieve consistency, the hospital needs to established standards for how it communicates with post-acute providers. If post-acute providers regularly receive the same standard packet of referral documents, they should be able to respond to hospital requests faster, which should shorten patients’ length of stay. There are always exceptions, but using a standard set of documents based on the level of care creates a more streamlined process.
Tracking
Once the standards are agreed upon, organizations must also track how they are practiced. Each transition should be measured by level of care to determine if there are any trends or opportunities in the care transition process. It’s also important check in with care transition teams to see if there are any barriers in the community and to give feedback on discharge planning. Below are four metrics all hospital case management teams should use to track post-acute care transition process.
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Four Measures to Track:
- The percentage of initial referral communication that takes place within 24-hours of discharge, 48-hours and longer
- Referral patterns by individual case managers
- Post-acute behavior, including:
- Response times
- Readmission rates
- Declines (and reason)
- Volume
- Length of stay from admission to the first referral sent out, and length of stay from the first referral until the patient’s discharge by level of care
How do you ensure smooth transitions in your organization? Let us know in the comments!
