Coming out of COVID, it’s clear that people want to have control of their overall healthcare experience, and a lot of that centers in and around their home. Unfortunately, when people end up in a hospital, returning home in an efficient manner is often easier said than done. There are a several challenges in the transition of care journey:

  • Determining who is a high-quality post-acute provider.
  • Determining patient and family preferences on the next site of care and getting them involved in a shared decision-making process.
  • Determining who has availability and authorization to see the patient in a timely manner.
  • Providing ongoing support and coordination of care for additional needs like nutrition, transportation or durable medical equipment.

Maintaining Connection Outside the Hospital

The patient hand-off can be thought of as a two-part process. How do you get people home safely? And, how do you maintain a connection? 

If you’re a provider taking some form of risk, your ability to maintain connection with patients on their overall healthcare recovery is mission critical to population health initiatives. You’re likely thinking about a few things. First, how do you manage total cost of care with the very best outcomes?

Next, there is site-of-care selection, that decision-making process of who should go where and for how long. Should they go to a skilled nursing facility? Outpatient rehab? Or have home health support? There’s a lot of variability in that decision. Trying to get it to be as evidence based as possible can move the needle in terms of total cost of care.

Providing a Safe Landing Home

Data overwhelmingly shows that a majority of complications, readmissions, or tragic outcomes happen within the first seven days post-hospitalization. And, those first 72 hours are an especially vulnerable time. So front-loading your engagement, making sure all services are activated and coordinated, and if they’re going to be late for some reason, making sure there’s proactive communication, is important to a safe landing. 

When that’s done, you set yourself up for a positive journey. It puts you on solid footing for a good outcome.

The innovation here is not just transitioning care and forgetting about it. The next step is to uncover new sources of data beyond claims data or hospital EHR data.

Operationally, when this process doesn’t run well, it creates challenges around uncompensated care or avoidable days. When somebody is ready to leave the hospital but can’t find the next available spot for that safe landing, hospitals have to write off anywhere between $500 and $2,000 per patient, per day. 

Creating a Framework for Success

Moving forward, care is going to be delivered in three ways: in high-quality facilities; online with telehealth capabilities; and it’s going to be brought to you in your living room. If you’re a traditional healthcare provider organization or health plan, you’ll need to set up the infrastructure to activate, track, and manage care outside of the traditional four walls of a hospital. 

What do you need to do to bring that to life?

  1. Expand your existing network of partners outside of the hospital. A typical organization may have relationships with skilled nursing facilities and home healthcare organizations, but they don’t yet have relationships with meal delivery, transport, courier services, mobile imaging and lab systems. Expanding your post-acute network to include a diverse set of services, all connected in a digital network, will yield results right away. 
  2. Integrate virtual care assets. Virtual care came to the rescue in a big way during COVID. Whether it’s remote patient monitoring or telehealth encounters, most systems have started to make an investment in virtual care. Integrating it with your post-acute network is the second major component.
  3. Plan to deliver care in a new and meaningful way. When you have the first two pieces in place, you’re now in a position to start to tackle new care delivery innovation. It could be hospital-at-home, it could be SNF care-at-home, or chronic condition management at home. 
  4. Uncover new sources of data beyond claims data or hospital EHR data.The innovation here is not just transitioning care and forgetting about it. It’s maintaining connection and pulling back insights around social, behavioral, and functional health, and then acting on them in real-time.

Every organization is at a different spot but it’s time to graduate to the next level of innovation to deliver an at-home care model. This will help more people access care on their terms, in their homes, and maximize their healthy days at home.

Tune in to the Bright Spots in Healthcare podcast “How to Conquer the Transition of Care Journey,” where Dina CEO Ashish V. Shah shares a blueprint for creating an effective transition-to-home care model. 

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