Outside the challenges we are facing in present day medicine the beat moves in the world of business with new companies forming on a daily basis. Statistically many of them fail at a rate of almost 90% during the first year, and 50% by year five. What is the secret to success for the companies that not only thrive in their first year, but stay in existence beyond that five year mark? Of course there are numerous factors that impact their success, but market need, supportive funding, and having a proven strategy that is executed well seem to be some of the most important measures. Therefore, we as a medical community should follow suite by developing approaches that are supported by a record of success in managing cost while delivering quality care to the prospective readmission populations.
The following is a 6 step summary of a possible approach that could provide a solution:
- High Risk Identification - Everyone is currently migrating their actions toward trying to explore better ways of collecting and organizing system data into actionable reports. An approach that supports this action and delivers results is to utilize a Business Intelligence Dashboard that segments data in easily defined demographic and population trend information. Once the system is established and in place it can be used to impact outcomes by using it to also track patient interventions that are most effective in specifically defined populations.
- Proactive Stratification with Behavior Change Assessments - One of the reasons the medical community seems to be struggling with the issue of readmissions is due to a resource allocation challenge. Understanding the people you serve is key to providing the resources necessary to support their care. One of the best and most accurate ways to do this is to assess the motivation of patients in addressing their own care. By providing this assessment to all identified high risk patients, system actions can be aligned to support a lean approach to care. By incorporating this information into the current EMR, patients are identified at entry and receive a focused approach that initiates the efforts at avoiding readmissions.
- Patient Centered Care Teams - It has been clearly shown in research that most readmissions occur within specific sub-populations of the health system. With this knowledge systems should design a multidisciplinary approach that supports improving self-care deficiencies in high risk populations. By engaging patients based on their motivation level, care and education can be tailored to meet their needs while limiting the impact on inpatient flow and hospitalist productivity. The addition of this focused inpatient team can connect the various entry point in the hospital, and utilize an integrated care plan that promotes improved communication regarding the patients treatment goals and intervention needs.
- Upstream Collaborative Discharge Planning - The Beryle Institute has done a great job of isolating some of the challenges that occur with readmissions to identify a lack of patient education as one of the leading causes. By dedicating the efforts of a collaborative team that works from a transitional care plan that guides both the inpatient and outpatient care education, the comprehensive holistic needs of the patient are met while increasing self-care confidence and compliance.
- Community Based Partnership for Ongoing Care - The focus on where readmissions originate from should be central to determining solutions that reduce avoidable readmissions. After discharge patients return to the community, therefore establishing a partnership with organizations designed to manage care in their homes in the community. To adequately support these individuals and their families in their outpatient care it would make sense to enlist the help of agencies specialized in this delivery of care. One of the best examples of this type of organization comes from the hospice and palliative care medical community. Hospice and Palliative Care organizations have the resources to support both the clinical and operational needs to deliver care to chronically ill populations. They have proven track records of successfully managing cost because the have to deliver all the needs of the patient based on a tightly fixed daily per diem rate of reimbursement. Therefore, they have become adept and designed systems to support the quality care of their patients, and minimizing the risk of avoidable hospitalizations that aren't covered in the per diem rate. Another benefit is their history high satisfaction rates by the patients and families they serve. By creating risk-based partnerships under the Shared Savings Program both the hospital and community-based organization can benefit from the new rules addressing care coordination reimbursement, and also deliver quality comprehensive care that will minimize the possibility of avoidable readmissions.
- HIE Solution for Secure Integrated Communication - Having access to real time accurate medical information by the entire team of care is a necessity in promoting safe quality care. Currently there are some solutions on the market that utilize mobile platforms to exchange real-time secure diagnostic information that aids in delivering quality care. It also reduces the financial load on paying for the upgrades that act as the foundation for all the ancillary facilities to participate in the patients care.