Managing a patient’s transition from one area of care to another, known as Transitional Care-Case Management is a critical feature of improving healthcare outcomes. The process aims to identify and overcome obstacles that may hinder successful transitions while working to fill in any gaps that would otherwise be seen in a patient’s care. The overarching goal is to provide a patient with an easy transition that’s not only efficient but also reduces costs by lowering rates of readmission.
According to estimates from the Medicare Payment Advisory Commission, upwards of 12 percent of re-admissions are avoidable, meaning over one billion Medicare dollars have been spent unnecessarily. An amount of this size echoes a cry for help throughout the healthcare scene. HealtheFirst is fully aware of the issues weighing down the quality and efficiency of care and has exerted passionate efforts to diagnose and mend weaknesses in the process and available technology.
Here are a couple of steps you can utilize today in order to improve the process of transitional care:
Step 1: Start Discharge at the Time of Admission
When a care manager learns of a patient being released, they should contact the case manager in order to lay the grounds for a successful discharge. This is the first step to reduce the risk of readmission. The care manager should be asking the case manager questions such as: What’s the care plan? What’s the expected length of hospitalization? What sort of facility will the patient be discharged to? What type of care will the patient need when they make the transition? Communication between care and case managers is especially crucial when looking to provide the patient with the most effective transitional care.
Step 2: Ensure Medication Education, Access, Reconciliation, and Adherence
When a patient faces hospitalization, due to either chronic or acute conditions, often that patient will receive new prescriptions/medications. The care manager must then cover the following: Education – the care manager works with the care team to make sure the patient or caregiver is informed about all new medications. Access – the ability to pick up and pay for prescriptions at a pharmacy needs to be discussed. Reconciliation – the care manager can collaborate with the facility or pharmacist on obtaining an accurate medication list for the patient’s follow-up visit with the PCP. Adherence – care managers ought to relay the importance of adhering to a medication plan to patients and/or caregivers.
Step 3: Arrange Follow-Up Appointments
The care manage ought to make sure the patient is scheduled for follow-up appointments and check-ins with their PCP seven to ten days after their initial discharge.
Step 4: Arrange Home Healthcare
The care manager should deem what’s best for the patient’s needs i.e… cooking, dressing, therapy, and other daily tasks after discharge. The care manager should then discuss with the patient or caregiver to set up follow-up care plans and make sure their living conditions are suitable for their needs.
Step 5: Make Sure the Patient Knows Their Transitional Care Plan
This one may seem a bit obvious, but having the patient fully understand their own transitional care plan is paramount to making the process run smoothly and free from complications. An easy way to make sure the patient fully comprehends the care plan is by having them teach back their discharge plan, diagnosis, medication, and calling schedule with their PCP. The care manager should provide the patient with a number to call if there are any further questions.
It’s indisputable that Transitional Care Management plays a critical role in today’s healthcare environment, which is why HealtheFirst challenges you to take steps toward providing the best care possible to your patients. The steps we provided are intended to help improve outcomes, mitigate costs, and ultimately improve your patient’s care experience. HealtheFirst has shown both the patient and provider-business benefits that are derived through the utilization of this extremely user and business-friendly resource.