Keep­ing an eye on dis­charged pa­tients

Modern Healthcare - - BY THE NUMBERS - By Michael Sandler

Hos­pi­tals are step­ping up their ef­forts to mon­i­tor pa­tients af­ter dis­charge to re­duce read­mis­sion rates that can lead to Medi­care penal­ties.

When the CMS rolled out its var­i­ous qual­ity-based in­cen­tive pro­grams, Roper St. Fran­cis Health­care started fo­cus­ing on pa­tients who reg­u­larly used the emer­gency depart­ment. Of­ten, those pa­tients didn’t have a pri­ma­rycare physi­cian, said Dr. Todd Shuman, chief physi­cian of­fi­cer at the Charleston, S.C.-based sys­tem.

Roper es­tab­lished the Care Tran­si­tions Pro­gram, which helps el­derly pa­tients rec­og­nize symp­toms of health de­cline and as­sists them in man­ag­ing their med­i­ca­tions. The hos­pi­tal de­ploys phar­ma­cists to ex­plain pre- scrip­tions to pa­tients, and phar­macy tech­ni­cians con­duct med­i­ca­tion rec­on­cil­i­a­tions, Shuman said. That might in­clude a call to the lo­cal phar­macy to find out the last time a pa­tient filled a prescription.

The Univer­sity of Colorado Health’s Me­mo­rial Hos­pi­tal as­signs a case man­ager to fol­low up with pa­tients at risk of heart fail­ure, stroke, pneu­mo­nia or heart at­tack, said Dr. Pa­trick Far­icy, chief med­i­cal of­fi­cer at the Colorado Springs hos­pi­tal. As at Roper, Me­mo­rial’s phar­macy tech­ni­cians do med­i­ca­tion rec­on­cil­i­a­tions with pa­tients and check to see whether they are tak­ing the drugs they were pre­scribed at dis­charge. Me­mo­rial staff keep pa­tients’ pri­mary-care doc­tors abreast of any hos­pi­tal ad­mis­sions and meds or­dered.

Providers in­creas­ingly are us­ing mo­bile tech­nol­ogy to track pa­tients post-dis­charge. The Hos­pi­tal for Spe­cial Surgery in New York City is de­vel­op­ing a mo­bile ap­pli­ca­tion that will al­low staff to in­ter­act with pa­tients re­motely post-dis­charge, said CEO Louis Shapiro. The app will up­date hos­pi­tal staff on pa­tients’ re­cu­per­a­tion, such as how well they’re walk­ing.

To re­duce read­mis­sions, providers must change their think­ing, rec­og­niz­ing that pa­tients are never fully dis­charged, said Dr. Chris DeRienzo, chief pa­tient safety of­fi­cer at Asheville, N.C.-based Mis­sion Health. Pa­tients move be­tween in­pa­tient, out­pa­tient and post-acute-care set­tings, and it’s es­sen­tial to ap­ply best-prac­tice in­ter­ven­tions at ev­ery level to make the great­est im­pact, he said.


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