When Strategy Meets Reality: Value-Based Discharge Planning

Recently, I had the pleasure of presenting at the California Hospital Association Post-Acute Care Conference, which brings together multiple stakeholders across the continuum, including hospital discharge planners, skilled nursing facilities, home health care services, rehabs, and more. One of the themes that ran across multiple presentations was how value-based reimbursement models are impacting these cross-continuum relationships.

During my session, I shared a value-based approach to discharge. Specifically, discharge planning is shifting from choice to informed patient choice, and from the acute to post-acute transition to discharge planning across multiple transitions of care.

What Patients Need

Most patients come into the hospital with the expectation that they’re going to go home. Instead, 42% of Medicare patients hear a version of: “Things are getting better, but you need post-acute care to help you recover.” That can be really hard for patients to digest when suddenly, they are being asked to choose a nursing home when they were expecting to return to their own home.

Now more than ever, hospitals are helping patients choose high-quality post-acute providers with, for example, lower readmission rates. Here are some actionable tips I shared at CHA that hospitals can implement to impact patient decision-making:

  • Even with patient choice regulations, it is OK to explain why quality is an important factor to consider when choosing post-acute care. Uninformed patient choice is not the intent of the regulations.
  • A paper list of providers is not enough. Case management departments need patient choice tools that support consistent messaging of preferred providers and showcase post-acute quality.
  • Hospitals should be up front about preferred providers. If you have an established network, be clear about which providers are part of it.

What Case Managers Need

During my session, I also shared feedback I hear from hospital case managers around patient choice tools. Here are some of the things they say:

  • “It can’t slow down my referral process.”
  • “All the information should be in one place. I can’t be sending my patient to this website or that website or handing them 10 different pieces of paper.”
  • “The facility that I show my patient needs to actually be able to take them – for example if they need dialysis or are on Medicaid.”

Discharge planning is shifting toward a more thoughtful approach that includes post-acute quality and outcomes and that emphasizes informed patient choice. Hospitals that are successful at implementing changes to discharge planning do two things well. First, they consider the needs of both patients and discharge planners. Second, they empower patients and their staff by giving them real tools, not just a verbal mandate. When I designed CarePort Guide, my goal was to make an easy-to-use and helpful tool for patients and discharge planners.

I left CHA feeling energized by the conference and our discussion. It’s an exciting time in healthcare. The growing links across the continuum are changing how we transition patients from acute to post-acute in way that is more patient-centered and focused on quality. And increasingly, we are moving the conversation from high-level strategy to an operational level that directly impacts patient care.

Learn more about how CarePort Guide supports informed patient choice.