Collaboration with hospital discharge planners can help hospices ensure smoother care transitions and timely referrals.
Securing timely referrals for eligible patients remains a challenge because many hospice patients receive care for only a few days prior to death. Additionally, careful management of discharges to hospice care is a growing priority as providers and payers seek to reduce hospitalizations, readmissions and emergency department visits.
Discharge planning can be a painstaking process, particularly for patients with multiple chronic conditions. Transitions between health care settings are a vulnerable time for patients, and more effective handoffs are a growing priority for referral partners, according to Lissy Hu, president of connected networks for CarePort, a WellSky company.
“Hospitals are focusing a lot more now on these care transitions into home-based settings, because there’s been an increase in the number of referrals,” Hu told hospice News. “Also, they’re having issues with capacity and length of stay, so they’re looking to streamline these transitions as much as they can. Because part of getting more patients to the hospital and turning over their beds is being able to find a provider that can take on that patient.”
Hospitals are focusing a lot more now on these care transitions into home-based settings.
Lissy Hu, president of connected networks, CarePort, a WellSky company
Among the challenges associated with a hospice discharge is ensuring the timeliness of care — finding a hospice that can be with the patient in their home as soon as possible, according to Joan Carpenter, assistant professor at the University of Maryland School of Nursing.
In 2019, 50% of hospice patients received care for 18 days or less, the National Hospice and Palliative Care Organization (NHPCO) reported. About 25% were enrolled for five days or less and 10% for two days or less.
A rapid response to referrals is a key value for referring organizations. A 2021 study by Transcend Strategy Group found that a speedy response is the most important factor that physician offices consider when referring to a home-based post-acute provider.
Throughout the transition process, effective communication among the hospital, the hospice and patients are families is the most critical element, according to Carpenter.
“It ultimately comes down to clear, high-quality communication, having a really good discharge plan and providing education to the caregiver — making sure people understand what they’re being advised to do,” Carpenter said. “There are ways to contact that hospice agency for questions prior to admission for any questions that they have. So, it’s all about communication.”
It ultimately comes down to clear, high-quality communication, having a really good discharge plan and providing education to the caregiver.
Joan Carpenter, assistant professor, University of Maryland School of Nursing
The patients that hospices typically care for are among those who have the most complex discharge planning needs, including elderly patients and people who have experienced a major life change or major surgical procedures, according to recently updated research.
The same study found that a lack of adequate discharge planning can result in readmission and decreased quality of life for patients.
Discharge to hospice includes some unique factors that must be taken into account, Carpenter said. This can include confirmation that the patient has a safe home environment as well as a family or other caregiver who can be with them 24/7.
Planning for symptom and medication management is an essential component of an effective transition to hospice, as well as screening for social determinants of health, Carpenter explained. Factors such as food security, support from family members and fall risk can impact a patient’s ability to receive care in their home.
The family also needs to know what to do if the patient’s condition changes, she indicated. If symptoms worsen or new ones appear or in the event of decline or a fall, they should know to contact the hospice rather than 911. This can be a change of mindset for many families who have become accustomed to utilizing hospital emergency departments.
Technology can be an important factor into care transitions, particularly when it comes to timely electronic communication and electronic health record (EHR) interoperability, Hu indicated.
“Being able to transfer electronic data reduces the potential for missing data or incorrect communication of data about the patient,” Hu said. “In order to really ensure safe and high-quality care transitions, you need that communication and collaboration piece. It’s being able to have electronic interoperability and conductivity, but then also being able to have that dialogue and collaboration.”
Companies featured in this article:
CarePort Health, University of Maryland School of Nursing, WellSky
