Education and Communications are Key to Successful Patient Transitions

By November 30, 2021 December 23rd, 2021 No Comments

Webinar Recap: Succeeding in Value-Based Care—Mastering Patient Transitions

“The pursuit of value-based care is fraught with challenges—operational, clinical, and financial—but you could argue that no area is more challenging than post-acute care and making sure that you have the insights and the transparency into patient care, and what happens to patients across multiple settings over time, particularly as they come out of hospitalization.”
—Brian Fuller, ICS CEO

November 30, 2021

The million-dollar question: What if value-based care organizations could seamlessly transition patients across settings, improving their experiences, and making money in the process by reducing readmissions? 

It’s possible. It’s also extremely challenging. 

In Part 1 of the new webinar series Perspectives Across the Care Continuum—Mastering Patient Transitions, value-based care experts at Integrated Care Solutions (ICS), National Health Care Associates (NHCA), Constellation Health Service, and UConn Health discussed barriers to successful patient transitions and solutions that these organizations are implementing to significantly reduce readmissions. 

Dr. Jennifer Baldwin, a hospitalist at UConn, kicked off the conversation by candidly explaining how managing patient transitions is one of the hardest responsibilities in healthcare. 

“I’ve realized speaking to colleagues and [admitting it] myself, the hardest thing and the thing we dislike most is the discharge process,” she said. “Most of us really enjoy taking a patient from the emergency department, understanding the complex diagnostic dilemma, and coming up with a treatment and management plan to help our patients hopefully get better. But the thought of transitioning them and actually working through this process of connecting them with their next providers and the nurses who are going to take care of them is a huge challenge because of the complexities. And the dynamics of every patient are different, and every patient has different access to care.”

She continued to say that over her 15 years of experience, there has been an emergence of nocturnists who choose to work at night because they don’t have to discharge patients. 

“That lets you understand how hard this work is,” she said.

The panel perspectives represented touchpoints throughout the continuum where a patient may experience the need for care—hospital and emergent care (Baldwin, UConn), skilled nursing and assisted living (Ann Spenard, NHCA), home health (Judy Walsh, Constellation), and care coordination (Andrea Rizik, ICS). The panelists spoke about the major barriers to successful patient transitions, which included: 

  • Silos of care 
  • Staff shortages / depleted resources
  • Poor patient hand-offs 
  • Plans falling through / missing details that matter (i.e. transportation to follow-up visit)
  • Not being able to control the care environment (i.e. especially in home health)
  • Discomfort talking about Advanced Care Planning
  • General lack of understanding around post-acute care capabilities

To answer that million-dollar question, the panelists landed on a few themes to achieve success. It boils down to increasing education and communication among patients, loved ones, and physicians within a provider network to ensure patients are getting “tucked in” across care settings. 

Below are a few standout insights from the webinar that value-based organizations like ACOs, DCEs, hospital systems, and payers can use to see tangible results in improving patient transitions and reducing readmissions:

Empower the Patient and Providers by Over Communicating
“Sometimes it’s not enough to have paperwork when our patients go back to the hospital. If we know that we’ve been having these conversations, our managers will call and talk to the case manager or the emergency room physician and say, ‘Just so you know, this is where we’re at with these conversations.’ So whenever we know that someone’s gone back to the hospital, we really try to have those urgent voice-to-voice conversations because by the time they get through the paperwork, it might be too late.”
—Jennifer Baldwin, UConn 

“I like to [frame the conversation around] the goals of care. Sometimes people don’t want to talk about end-of-life, but they can understand goals for care … ‘I want to get home, and I want to be able to walk to my mailbox. I want to be able to be with my grandchildren,’ or whatever it may be, having the conversations early on, and again, asking what the goals of care are [should reduce trips back and forth to the hospital].”
—Ann Spenard, NHCA 

“It’s not a one-time conversation. It’s really about what the person wants and watching for times to repeat the conversation based on how the patient has changed. Patients are constantly changing, right? So it’s a new day. It’s a new conversation based on what they’re able to hear, what they’re feeling, what that means for them, and listening for cues.”
—Judy Walsh, Constellation

Build Trust and Transparency within the Preferred Provider Network
“The top two things that patients are so fearful about are that we don’t know what’s going on with them or that we don’t talk to each other. So if you can solve those two problems using a preferred provider network, I think you have the best-case scenario for the patient, but it starts with knowing each other’s capabilities, making sure you have the capabilities that you need—and if you don’t—you need to develop them. Then make sure that everybody on the front lines is as excited about it as all of the management team is because the people who are actually taking care of the patients and calling each other need to be really excited about it and understand why it’s better for their patients for it to really stick.”
—Judy Walsh, Constellation 

“Whether a patient goes to a skilled nursing facility or home health, there needs to be realistic communication about their clinical capabilities and what services they’re able to provide the patient. If there’s not an OT on staff at a home health agency, for example, should they really be able to accept patients who have had catastrophic strokes? There needs to be open and honest dialogue about capabilities. I think the most successful preferred networks have frequent and open conversation between the health system and the providers making sure that this practice is carried downstream.”
—Andrea Rizik, ICS 

“Doctors don’t have a great sense of what happens in skilled nursing facilities versus home health agencies. So [it’s important] for us to relearn the different capabilities of different networks. I love the idea of having a handful that I have more familiarity with … [for example,] if there are referrals in our networks that have a secure HIPAA compliant texting app, I can reach them and actually give a warm handoff. If we have that for all of our patients, I think these transitions would be so much better for our patients and decrease readmissions.”
—Jennifer Baldwin, UConn

Educate About End-of-Life 
“If you can, talk about the end game. [For example,] dementia is a terminal illness, it’s irreversible. Most people don’t talk about that. Talking about the trajectory of disease states is very important. I think if we spend the time educating the patient, the resident, and the family around that, [understanding what happens at the end will help prevent hospital trips].”
—Ann Spenard, NHCA 

“I was going to get a glass of water, literally right before this webinar, one of my colleagues stopped me and said, ‘Wow, I just made a patient hospice who’s been here 11 times in the last several months with the diagnosis of pancreatic cancer and I’m the first person who brought up hospice and end-of-life. And the patient said, if anyone offered this to us on our first admission, we would have much preferred to go down this path and had a much less rocky course for the last months of life.’’ We know patients actually live longer and do better when hospice and palliative care are involved in the beginning of a patient’s diagnosis. So I think it is so important to educate physicians and providers to feel comfortable with these conversations.”
—Jennifer Baldwin, UConn

“At ICS, we’ve empowered our nurses to educate. We have a Respecting Choices Educator who has educated and certified several of our other clinical integration nurses to be able to have those advanced care planning conversations, be able to transition the patient’s needs to the physician or to the advanced practice provider to have the conversations, discuss the possibilities, and pivot if the patient’s situation has changed.”
—Andrea Rizik, ICS 

Stay tuned for Part 2 of Succeeding in Value-Based Care in early 2022.

ICS helps organizations transform from fee-for-service to value-based care and delivers ongoing care coordination, consulting, and expertise in data-driven processes necessary to achieve quality care and financial success. If you are an ACO, DCE, hospital, or payer in need of a partner with expertise in value-based care and proven results working with risk-bearing organizations, contact ICS today for a free consultation.


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