With value-based care as the cornerstone for future care delivery, providers who can meet the interoperability needs across the healthcare continuum will stay one step ahead of the competition. Many health systems and collaborative care organizations have already begun to tackle the interoperability challenges of connecting physician practices, laboratories, clinics and hospitals to produce a seamless flow of information among primary and acute care providers, but a critical interoperability component may be absent.
While acute care organizations have access to patient information related to hospital stays or visits to physicians within the health system, the electronic health record (EHR) typically does not often include post-acute care documentation. To address this, acute care organizations should consider expanding the longitudinal patient record to include home medical equipment (HME), home health and hospice care data. Healthcare organizations, then, will have access to information about patient progress, compliance with therapy and symptom exacerbation after discharge.
Proactive development of initiatives to minimize readmissions, better manage chronic disease care and improve patient experiences, can be significantly improved if providers have access to a holistic view of individual patients, as well as specific populations. Such strategies that healthcare organizations should consider when engaging in collaborative efforts across the care continuum to strengthen financial performance for all providers – both acute and post-acute – include:
- Build strong partnerships with post-acute providers.
To support the financial and clinical quality goals of the organization, an acute care provider should create sustainable, long-term relationships with post-acute providers that go beyond individual patient referrals. Because acute care providers face reimbursement penalties for readmissions within 30 days, it is critical that post-acute care providers are included as part of the care team, with access to critical patient information such as diagnoses, medical history, discharge plans and expected outcomes.
In addition to providing care that may prevent readmissions, post-acute providers’ documentation of patient care after discharge can contribute to a more robust longitudinal record that benefits providers downstream in the healthcare continuum. The ability to access and view the entire patient record rather than a partial record, enables clinicians with the necessary data to make fully informed decisions regarding patient care.
- Support relationships with the right technology.
Establishing a valuable collaborative relationship with post-acute providers requires implementation of the right technology. Because electronic health records (EHRs) are becoming more prevalent throughout post-acute care, the ability to capture and transmit electronic data is now available.
Health systems’ use of open platforms and application interfaces that integrate disparate systems and enable access to information creates the opportunity for information to flow between acute care and post-acute care providers. Although standards for healthcare information technology systems are still emerging, the use of HL7 standards for the exchange, integration, sharing, and retrieval of electronic health information and modern web-based solutions greatly improve the interoperability between disparate systems.
- Enhance acute care data for quality improvement.
Ensuring interoperability of post-acute and acute care providers in a collaborative relationship produces additional benefits beyond improved individual patient care. Although hospitals routinely mine information from their own data warehouses to identify opportunities to improve patient care on a larger scale, the data only provides insight into a patient’s stay in the hospital. Adding post-acute care data that includes supplies, home-based therapy and medications required for care following discharge provides a complete overview of clinical and financial aspects of treatment.
Post-acute care’s increasing reliance on automated billing systems also provides the advantage of real-time cost information, as opposed to historical claims data more commonly available to hospitals. Access to this information enables more accurate patient care cost predictions, based on diagnosis, location of care and length of care.
In addition to the more complete financial overview, the clinical perspective related to chronic disease management in post-acute care strengthens a healthcare organization’s population health management strategy. Improving patient education and care plans for patients with chronic obstructive pulmonary disease, for example, is more effective when the potential challenges of purchasing, receiving and using oxygen at home are better understood. The ability to predict the risks for non-compliance with discharge instructions enables a population health manager to address needs before the non-compliance results in readmission or exacerbation of the disease.
As healthcare continues its transformation from volume-based to a value-driven, patient-centric industry, the use of technology to enable collaboration across the entire healthcare continuum is critical. By connecting disparate healthcare systems– including HME providers, home health agencies and hospice organizations – hospitals and health systems can greatly enhance financial performance, clinical care and operational processes to boost their value proposition to both patients and referring physicians.
