Hospitals Pursuing Many Paths to Connect with Discharged Patients
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For hospitals, maintaining patient health and their own financial health increasingly depends on having consistent, meaningful interaction with patients outside the hospital. The imperatives to reduce readmissions and improve patient satisfaction have been catalysts for how hospitals interact with discharged patients.
Post-discharge patient engagement is getting results as well as attention. Effective solutions range from high-tech — such as advanced telemonitoring programs and the thousands of mobile applications on the market — to low-tech, high-touch programs that rely on transition coaches, home visits and follow-up phone calls.
These and other approaches all have a place in improving patient engagement. Leading innovators tend to be leading integrators, because they have successfully combined proven practices with emerging technology tools to provide better outcomes. Many believe that the technology available now is functional and mature enough to effect a meaningful reduction in readmissions. The challenge lies in gaining the patient understanding and designing appropriate processes to use technology tools most effectively.
“The biggest challenge now is that evidence-based protocols haven’t been established so hospitals can know which patients can best be served by remote monitoring and other technology that is available,” said Nesim Bildirici, founder, president and CEO of AMC Health, which develops remote patient monitoring systems that provide real-time data to health care providers.
“The awareness is there, the motivation is there, but we just aren’t at the solution stage yet,” said Colleen Sweeney of Sweeney Healthcare Enterprises, a consultancy that specializes in helping hospitals improve their patient empathy and the patient experience.
There are literally thousands of targeted solutions and other resources available to support patient engagement. Most options fall within five general categories:
- Discharge tools
- Remote monitoring/Telehealth
- Mobile applications and sensors
- Telephony and Web-based programs
- Transition coaching
Some initiatives that have been very effective at reducing readmissions have combined elements from these categories. For example, Geisinger Health modernized the traditional post-discharge phone call process by adding an interactive voice response (IVR) system for cardiac patients to answer questions and provide information. The 30-day readmission rate fell by 44 percent and Geisinger calculated that the program saved $3.30 for every $1 it cost to implement.i
Here is an overview of some of the innovative tools and approaches hospitals are taking to improve post-discharge patient engagement.
Mobile Applications
Mobile technology is perhaps the most visible resource being applied to improve patient engagement. There are thousands of mobile applications related to health and fitness already available. Apps increasingly include sensors and wearable devices, sales of which will quadruple from $1.5 to $6.0 billion from 2014 to 2016, according to the American Telemedicine Association.
“There are a lot of applications and other technology out there, but unless there is feedback from a care expert I don’t think they are going to be effective,” said Bildirici.
Dr. Pravene Nath, CIO of Stanford Health Care, agrees. The health system recently released myHEALTH, an iPhone® application for users to record health data and share it with their doctors within the Stanford system. myHEALTH includes an interface to Stanford’s Epic EHR system so input from the mobile device can be integrated to the patient record.
“We believe that people will want to have that experience with a trusted provider, one that can cover the entire continuum of health, wellness, prevention, diagnosis and treatment, providing leading edge and coordinated care,” said Dr. Nath. “The really great apps will be differentiated by their ability to simplify the complexity of health care and to deeply connect with the entire care process both clinically and logistically. That’s why the integration with core IT systems, such as Epic for the electronic health record, is so important. This is not easy to do, and we’re early in the journey here.”
Some of his advice to other health systems that want to pursue mobile applications includes: “Be cautious about releasing mobile technology that appears to the user to be free-standing and not connected to your core mechanisms of delivering care. One-off apps are faster to deploy, but unless they occupy a unique niche that solves an important problem, they can become confusing, disconnected and irrelevant.
Discharge Tools
Patient assessment discharge tools have been proven effective in multiple settings but have also proven challenging to implement. The American Hospital Association 2015 Private Sector Discharge Tools Report presents case studies about five successful programs, but also notes: “At this time there is no standardized hospital discharge tool. However, the Department of Health and Human Services (HHS) has developed a standardized patient assessment tool to capture clinical and demographic characteristics of patients across post-acute care settings. This tool exists in two forms — the Continuity Assessment Record and Evaluation (CARE) Tool and the B-CARE tool. However, these two tools do not identify the best next setting for patients being discharged from general acute-care hospitals, and providers report both tools are burdensome and lack the ability to capture the full spectrum of a patient’s medical complexity to determine post-hospital care needs.”
In August 2014, the CMS suspended the use of B-CARE in its bundled payment demonstration project. The unrelated IMPACT Act that Congress passed in September 2014 creates patient assessment and data reporting requirements that are scheduled to take effect in 2016, including discharge data exchange requirements.
Health systems that worked through the challenges of implementing discharge tools have been rewarded. Here are some examples:
- Illinois-based Advocate Health Care reported it reduced readmissions for COPD patients by 50 percent and by 16 percent for congestive heart failure patients after using discharge tools to identify high-risk patients.ii
- A study of the Project BOOSTing (Better Outcomes by Optimizing Safe Transitions) care transitions toolkit that is used by more than 180 hospitals found a 13.6 percent average reduction in the 30-day all-cause readmission rate.iii
- Geisinger’s ProvenHealth Transitions program helped reduce readmissions for its entire Medicare patient population by 36 percent.iv
“The best time to improve post-discharge care is while the patient is still in the hospital,” said Sweeney. “However, the last hour before discharge is not ideal, because patient and family anxiety is heightened just before the patient is preparing to go home.”
Telehealth/Remote Monitoring
As with mobile applications, the telehealth solutions category is rapidly expanding and there are numerous solutions available. Program success often depends more on how patients and providers use the data than on the technology used to collect it.
“If there is a system in place to automatically collect and monitor data, then case managers can work much more effectively because they can spend more time on emergent issues instead of calling patients to ask for monitor results,” said Bildirici. “Clinical teams can have much more meaningful conversations with patients when they are empowered with tools that allow them to communicate data on a real-time basis.”
That is the principle behind a current remote patient monitoring pilot being conducted by Dr. Rita Ghatak of Stanford Health. “Remote monitoring shouldn’t be used in isolation. The follow up calls and visits are still very important,” she said. “We tell patients remote monitoring is not a life-saving tool, it is a tool to improve their awareness and help them with self-management.”
Transition Coaching
Transition coaching is valuable in its own right and can enhance the value of telehealth and other patient programs. Transition coaching can take the form of patient education at the bedside, formal models that have been developed by universities and public sector organizations, and commercial services like Walgreens’ WellTransitions® program. WellTransitions is intended to improve medication adherence, which is a key to preventing readmissions. Valley Baptist Health System credits the WellTransitions program with contributing to a 57 percent reduction in 30-day readmission rates relative to a control group in 2013 and up to 68 percent for some patient populations (see details in this case study).
Follow-up Contact
New twists to low-tech and no-tech options like follow-up phone calls and home visits can be highly effective. “Nurses have so many responsibilities to juggle that calls fall down the priority list while they are dealing with immediate patient needs in the ward,” said Sweeney. “I’ve seen hospitals improve the post-discharge call effectiveness by having volunteers make routine calls. They don’t get into any clinical discussions; if the patients have questions or concerns they are flagged for follow-up from a nurse or specialist.”
Other hospitals have established small call centers with employees whose primary responsibility is to make follow-up calls to patients. Email, websites and text messages provide additional channels for engaging patients. The use of these channels and the services available through them will increase as the generation that grew up with Internet access and mobile phones becomes a larger proportion of the patient population.
“Patients are becoming more like consumers. Outside health care, consumers do much more self-service, from banking at an ATM instead of a teller, to online travel check-in,” said John Adractas, chief marketing and growth officer at Simplee, which provides self-service payment solutions for hospitals. “Unfortunately, consumers rank health care near the bottom of the list when it comes to clarity and convenience, and also for customer satisfaction. That needs to change, because patient satisfaction is becoming so much more important.”
i “Can Telemonitoring Reduce Hospitalization and Cost of Care? A Health Plan’s Experience in Managing Patients with Heart Failure,” Daniel D. Maeng, PhD, Alison E. Starr, DBA, Janet F. Tomcavage, RN, MSN, Joann Sciandra, RN, BSN, CCM, Doreen Salek, BS RN, and David Griffith, BS1, Population Health Management 2014.
ii Private Sector Discharge Tools – Samples of hospital discharge planning tools that strive to improve transitions to post-acute care and reduce readmissions. American Hospital Association, January 2015.
iii BOOST Preliminary Results from Pilot Sites. Accessed from the Society of Hospital Medicine website on February 25, 2015: http://www.hospitalmedicine.org/Web/Quality___Innovation/Mentored_Implementation/Project_BOOST/BOOST_Preliminary_Results_from_Pilot_Sites.aspx.
iv Private Sector Discharge Tools – Samples of hospital discharge planning tools that strive to improve transitions to post-acute care and reduce readmissions. American Hospital Association, January 2015.
