Cultivating cross-continuum communication after hospital discharge

When a patient enters the hospital, whether for a planned procedure or an emergent one, their physician isn’t necessarily aware of the impending treatment. In fact, physicians often remain in the dark about patients’ acute care outcomes and the need for follow-up care-especially if the doctor is not part of the hospital’s network. 

This lack of awareness and involvement not only puts the patient at risk but puts the physician at a disadvantage when trying to sustain care continuity, foster prompt post-discharge follow-up, and support a patient-centric health experience. However, there are certain things a physician can do to guarantee better communication and collaboration after a patient’s acute care stay. 

Through these activities, providers can better connect and remain in contact with patients after they leave the hospital to sustain positive outcomes and identify potential problems that could lead to readmission or other complications.

• Ensure the hospital has access to a strong post-acute network. 

Oftentimes when patients are hospitalized, it is clear they will require some type of specialized care after discharge. Perhaps they had a stroke and have multiple comorbidities and need to transition to a skilled nursing facility to begin the recovery process. Or, maybe the patient has had a knee replacement and must attend physical therapy sessions at a rehabilitation center for a brief period. 

If the hospital has a haphazard process for connecting a patient with the most appropriate post-acute providers, it can result in the patient going to a location that is not the best fit, which could affect outcomes and patient satisfaction. However, if the hospital has access to a robust post-acute network and can easily communicate details about the patient with the network, then the hospital is more likely to facilitate a better match. The patient can learn about a variety of choices that could meet their needs and seamlessly move to the selected location when the timing is right. 

• Learn how the hospital coordinates care after the patient leaves the acute setting.

In addition to a solid network, hospitals should have strong processes for communicating with post-acute providers at discharge. For example, if they have methods for sending relevant portions of the patient’s medical record to the facility ahead of the individual’s arrival, then the post-acute provider can sufficiently prepare for the visit, ordering medications, treatments, and therapies to begin as soon as the patient arrives on site. This can prevent care lapses and ensure greater continuity. 

• Participate in care management activities.

It used to be that once a patient left the acute setting, the hospital lost sight of the individual, leaving it up to the patient and their primary care physician or post-acute provider to manage care. However, now that hospitals are being held financially responsible for unnecessary readmissions, more and more acute facilities are looking for ways to communicate and coordinate with the patient and care team after discharge. 

Forward-thinking organizations are relying on care coordination solutions-in some cases, using apps that promote communication across settings. These apps act as virtual command centers, where different stakeholders-the hospital case manager, post-acute provider, primary care physician, pharmacist, patient, and family-use the app to communicate about the patient’s current condition. Through this app, physicians can monitor patient metrics, such as blood pressure and heart rate, which are collected through a Bluetooth-enabled device. Team members can intervene if they see worrisome metrics. Similarly, a patient or family member could reach out to the entire care team with a question and receive a response from the most appropriate provider in a timely fashion, potentially heading off issues. 

This type of cross-continuum communication is relatively new, and the idea of using an app to engage different providers is on the forefront of change. However, those physicians who are willing and committed to improving collaboration may see real benefits from these care coordination solutions in terms of addressing patient needs and avoiding negative situations. 

• Engage the patient and caregiver.

In addition to supporting better care management, physicians can also use these tools to foster patients’ commitment to long-term recovery. For example, providers can use these tools to send patients educational materials about their conditions, answer questions from caregivers about any issues that arise or encourage individuals to follow long-term wellness plans, including exercise programs or specific diets. 

• Look for opportunities to assist with population health. 

Healthcare organizations are seeking ways to manage the health of different populations, such as those patients with diabetes, asthma, congestive heart failure, and other chronic conditions. The idea is to be more proactive in managing these patients to avoid trips to the hospital-especially repeat visits. The more physician practices can partner with hospitals in managing these patients’ care, the better. This may involve using technology to identify high-risk individuals-perhaps ones who have had multiple hospital visits-and reaching out to provide more proactive, ambulatory services, such as A1C3 screening tests for diabetics or creating an asthma control plan. 

Remaining open, engaged is the key

Emerging payment models will require hospitals and physician practices to work more closely together in meeting patient needs and managing patient health. The more amenable a physicians and practices are to working with nearby hospitals to support continuous care after patient discharge, the better their patients’ outcomes and overall health will be. 

By participating in efforts to streamline communication, promote collaboration and act as partners in care delivery, physician practices can set the stage for care that is truly patient centered. 

Mary Kay Thalken is chief clinical officer at Ensocare.