Issued in September, the Center for Medicare & Medicaid Services’ final rule on planning for post-acute care requires hospitals to fully map out the patient’s transition from hospital to post-acute care site, be it the home (through a home health agency), rehab facility or long-term care facility. That includes taking into account patient preferences, ensuring that patient records are accessible in an electronic format, and providing up-to-date research on the PAC care provider.
In the past, discharge planning included many phone calls, paper forms and research – a process that might take hours, if not days, and possibly delay discharge or result in placement in an inappropriate or sub-standard program. But with mHealth tools, a hospital might be able to call up the information on a laptop, table or smartphone within minutes, share that data with patients and care providers and seal the deal on PAC transfer in less than an hour.
“This eliminates a lot of trial and error,” says Cynthia Onorevole, LSW, a clinical social worker for the orthopedic, neurology and neurosurgery departments at Pennsylvania Hospital. “Previously, I could have worked on patient placement for several days … but now we’re (completing the discharge planning process) with a lot more efficiency.”
Connected health platforms (Onorevole uses one developed by Philadelphia-based Repisodic) collect the necessary data from several disparate sites to create one resource, accessed on a mobile device. The platform also pulls in hospital and payer data, including the patient’s medical record and insurance coverage, and uses a HIPAA-compliant messaging tool to enable quick communication and collaboration.
“If you’re using a phone you have to factor in the many times the phone call goes unanswered,” she says. “Then you have to keep calling back.” With a messaging platform, “you send a message and they answer it when they can.”
The idea, she says, is to create a more complete profile of a patient’s post-acute needs, then find the suitable PAC provider to meet those needs. And it encourages the patient to play a more active part in choosing that provider.
mHealth tools, meanwhile, give hospital officials the power to gather more of that data more quickly, present it to the patient at the bedside, and pull in other decision-makers to develop a comprehensive care plan.
“This empowers the patient and their support system,” she says. “Patients are more confident that they’re getting the right care, and they’re more happy with that care.”
“Today’s rule is huge step to providing patients with the ability to make healthcare decisions that are right for them, and gives them transparency into what used to be an opaque and confusing process,” CMS Administrator Seema Verma said in a press release announcing the final rule. “By demystifying the discharge planning process, we are improving care coordination and making the system work better for patients. Patients will now no longer be an afterthought; they’ll be in the driver’s seat, playing an active role in their care transitions to ensure seamless coordination of care.”
Onorevole says an mHealth platform also allows care providers to “cast a wider net” for appropriate PAC services, by plugging in specific needs like catheter or ventilator care and including quality ratings and reviews. Again, all that information is presented to the patient and care team at the bedside (or wherever they may be), giving them the opportunity to make a more informed decision in a much quicker fashion.
This, in turn, reduces costs by shortening the patient’s stay in the hospital, and improves outcomes by reducing the chances of a patient being transferred to the wrong facility, and then being transferred to another facility or rehospitalized.