In addition to the moral imperative of improving care for some of our highest need patients, effective and integrated transitional care can impact delivery cost, health outcomes, patient safety and many other priorities that all of us as executive leaders are facing each day.
When designed well, successful complex care management promotes value-based care and focuses on high-need, high-care patients to have the most impact. Since the implementation of the ACA, payers, providers and partners have all expended significant energy on improvement strategies and financial incentives. Recent studies have emerged analyzing the effectiveness of various care models providing coordination of services for HNHC patients as they transition between the acute, post-acute, and outpatient settings.
While integration of preventive and restorative services into the continuum of care continues to improve, most existing models of transitional care still invest heavily in human resources, and very little in more advanced health information technology. They also miss many patients who are negatively impacted by social determinants of health and may suffer from lack of access to services. As a result, the system is still seeing tens of billions in wasted expenditures for unnecessary medical treatment due to poor transitional care.
To make further progress in addressing patient safety, health equity, cost and other significant care drivers, boards and C-suites can influence improvements to transitional care through diversified decision-making, accelerating innovation and targeted data analytics.
Embed Clinicians in Decision-Making
Multidisciplinary teams that include physicians and clinicians from various points on the care continuum–from primary care to post-acute and nursing home care—are vital to developing well-informed, practicable and effective solutions.
Giving clinicians both a seat and a voice at the table brings a front-line perspective to decision-making. Cross-team collaboration between physicians, nurses, advanced practice providers, behavioral health specialists, social workers and others will help create holistic interventions and improve implementation, buy-in and adoption across the system.
In the same vein, consider integrating related organizations and institutions, like community health clinics and SNFs, in these processes. Patient experience doesn’t end at the doors of our facilities, and intentional cooperation across siloes and with other service providers can be led from the top.
Invest to Drive Innovation
The rapid transformation of digital health and care delivery models during the COVID-19 pandemic and beyond offers the opportunity to make further inroads in improving transitional care. Think critically and systemically about how innovative, technology-driven solutions can help alleviate the barriers of manual transitions.For instance, the hospital-at-home model is gaining more support from CMS and providers alike. The uptick in digital health adoption during the pandemic has led to more “wired” HaH models with improved integration through EMRs across the care continuum. This improves monitoring and increases compliance with follow-up visits and other services, while reducing staff burdens and access issues.
Measure What You Want to Improve
A sustained investment in in advanced data analytics can help create meaningful metrics around transitional care. To determine some initial areas of focus, consider which metrics are most costly to both the organization (length of stay, readmission, burnout) as well as to patients (outcome disparities, increased morbidity). Identify where transitional care processes intersect these metrics and this will be the starting point for multifunctional, team-driven solutions. Benchmark, measure regularly—and embed targets into organizational goals for maximum impact.Transitional care remains a pain point for our hospitals and health systems, physician offices, and ancillary care delivery, but innovative, team-based decision-making can improve continuity in the care continuum. Solutions will need to be directed from the highest levels of healthcare organizations to bridge the gaps between functions and dedicate sufficient resources to improve capacity and continuity between providers. Including physicians and clinicians in decision-making and striving for innovation in interventions will be critical in creating impactful and lasting solutions and a healthier future for all.