Earlier this year I had the pleasure of welcoming my son, this awesome little human that I love oh so much! Prior to his arrival, I was the primary caregiver to my mother, who has a history of stroke, diabetes, and end-stage renal disease. That care-giving role for my mother didn’t change when I became a mother.
During my pregnancy, my mother had a fall that further complicated her care. She was sent to a long-term care facility for rehab. With the pressures of pregnancy and new motherhood, I became acutely aware of the shortcomings in discharge processes and care management as I contemplated how we would cope when she returned home. I could clearly see that there would be clinical and non-clinical needs for my mom that would fall through the cracks. I needed help and there wasn’t a coordinated, informed source to tell me what help was available. A big part of the confusion involved paperwork — all the forms and documentation needed to get my mom the equipment she would need.
I’m not alone in this dilemma. It is mostly women who do the caregiving in our society, and as the age of new motherhood has risen, the number of women juggling parenting and caregiving for elderly parents also has risen. I suspect there are a lot of women like me, who could care for their parent when they were childless, but find that same task far less manageable when their first child arrives. Even for families without young children, helping a family member transition home after a long inpatient stay can be daunting. A study done in Great Britain in 2015 showed that nearly 20% of people discharged from a hospital in the previous 3 years did not feel they received all the social care support they needed. I suspect the numbers in the U.S. are similar.
The inadequate discharge processes are a serious gap in effective care management.
Readmissions and poor outcomes are the inevitable result when there is confusion and lack of coordination. And often, it’s the simple things that are overlooked that make a difference. A patient survey done at a teaching hospital in 2015 found that many patients were readmitted before their post-discharge follow-up appointment with their physician, which was often scheduled two weeks or more after discharge. Simply moving that appointment up, or providing telehealth follow up in the days immediately after discharge, could prevent some readmissions. While it may be simple things that make a difference, the issue is that there are dozens of simple things like this that can affect how well a person transitions to home. The tasks aren’t complex, but they are time-consuming and burdensome, especially for a patient, like my mom, who has multiple conditions and illnesses.
Since 2012, when the Centers for Medicare & Medicaid Services (CMS) established penalties for hospitals that readmit too many Medicare patients within a 30-day window, readmission rates have fallen. For 2018, CMS is adding penalties for excess readmissions to skilled nursing facilities. It’s a challenging goal for both hospitals and nursing facilities, but the CMS program shows that, with an incentive to change, progress can be made.
The problem isn’t limited to elderly patients, either. It’s a big issue for patients of all ages and their families, especially when a long inpatient stay or a chronic illness is involved. Health plans are well positioned to help their members lower readmissions through a comprehensive care management strategy. This is not a new idea. What is new is that there are now automation tools to help discharge planners and care managers ensure the process is comprehensive. And automation can lower administrative costs and allow health plans to help more members make the transition smoothly.
For example, you can build an automation solution with custom rules and objects that help care mangers and nursing staff proactively identify programs for your members. Using eligibility and utilization information you can identify social services that can improve the healthcare experiences and health outcome of an individual post-discharge, such as adult daycare and food assistance programs, such as Meals on Wheels. In addition to streamlining core processes, using a good automation tool can reduce costs. In my work with health plan clients, I’ve seen clients experience 50% improvement in productivity gains, allowing them to serve more of their members and free up clinical staff time for the important clinical work.
There are many more examples of how analytics and automation can be paired in the care management process to ensure that patients get the care and support they need after discharge. It’s time we started using these tools to help every patient.