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Discharge planning during the COVID-19 pandemic: a year in review

The pandemic’s impact on discharge planning

As the US experienced its first COVID-19 surge in March and April, hospitals reached or exceeded patient capacity, and many post-acute providers were unprepared to accept COVID-19-positive patients – whether due to isolation challenges within the facility or a lack of personal protective equipment (PPE) to ensure the resident and staff safety. During this time, hospitals faced bottlenecks in the discharge planning process. To determine where and when patients could be discharged, communication with post-acute providers was more critical than ever to ensure safe, smooth patient transitions. Many hospitals also moved non-essential discharge planning staff offsite, and limited or restricted family visitations to inpatient residents. These measures presented challenges during the discharge planning process, as patients being discharged to post-acute care may be older, struggling, or have hearing or cognitive impairments that can make the process confusing or stressful.

Case management has been more complicated during the pandemic, not only because families have not been present during the discharge planning process, but also because families and patients haven’t been allowed to tour potential post-acute care facilities. To help ensure the safety of residents and staff, CMS announced the restriction of all nursing home visitors – except in certain compassionate cases – effective March 13, 2020. These measures not only put an immediate stop to visitors for existing nursing home residents, but also eliminated the possibility of in-person tours and visits at post-acute care facilities for patients and families. 

During COVID-19 hospital visitor restrictions and post-acute facility lockdowns, CarePort Guide and CarePort Care Management have helped enhance patient-provider communication regarding a patient’s next level of care. Care Management allows for streamlined streamlines transitions of care – strengthening relationships with a comprehensive post-acute referral network, allowing for closed loop referrals and increasing discharge planning efficiencies. Care Management also provides robust discharge planning analytics that enable hospitals to better monitor post-acute provider performance and patient outcomes.

CarePort Guide, which can be integrated within Care Management, is an interactive tool used by discharge planners, care managers, patients and families to find high-quality post-acute care for a patient’s specific needs, CarePort Guide offers detailed information on every Medicare-certified post-acute facility in the country, including quality ratings and an interactive guide with virtual tours and pictures for each post-acute provider – without ever having to step foot in the facility.

Discharges to home-based care

The COVID-19 pandemic has also accelerated a shift to home-based post-acute care, rather than institutional-based care at nursing homes or skilled nursing facilities (SNFs). Prior to the pandemic, hospitals were already trending toward limiting visitors from outside organizations – including home health liaisons – and COVID-19 has likely sped up that trend. In many markets, vendors are completely remote, and they may never be allowed to return onsite.

With patients increasingly being discharged from hospitals to home health rather than post-acute care facilities, CarePort Guide helps identify home health care agencies, populating detailed information regarding every Medicare-certified home health agency in the country to help ensure patients receive high-quality care post-discharge. Once in home health care, CarePort Connect also offers a robust home health agency analytics and reporting tool to help evaluate home health agency performance across key measures, including timeliness to start of care, admission rates and discharge rates.

Where discharge planning is now

As frontline workers, nursing home residents and the general population are vaccinated, hospital and post-acute facility restrictions are slowly being lifted. Some hospitals are relaxing restrictions and families – one person, at least – are allowed onsite, and CMS has issued revised guidelines for nursing homes, effective March 10, 2021, allowing indoor visitors at post-acute care facilities in most cases.

Acute and post-acute care may never return to its pre-pandemic ways; for example, who will be allowed onsite at hospitals ­– such as home health liaisons – may examined more closely in the future. Tools within the CarePort product suite – including CarePort Care Management, CarePort Guide and CarePort Connect – will become even more essential because they can help mitigate misinformation or communication lapses that have resulted from this move to remote or offsite patient care. Throughout the COVID-19 pandemic, discharge planning ­– and a shift in post-acute care references – have presented several challenges, but CarePort has helped facilitate increased transparency and real-time communication between patients, families, case managers, discharge planners and post-acute care providers to help ensure smoother care transitions and positive patient outcomes.

Looking for discharge planning software? CarePort offers a robust care transitions solution, leveraging a national provider network to streamline patient transitions and expedite authorizations to the appropriate next level of care. Learn more.

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