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5 Keys to Better Care Coordination and Discharge Planning

January 18, 2021

Rita Patel, RN, BSN

5 Keys to Better Care Coordination and Discharge Planning

Discharge delays are frustrating for case managers and costly for hospitals. Here’s a typical scenario: You spend all day working to discharge a patient to a skilled nursing facility, but at 5:00 PM, you still can’t reach the patient’s daughter, and you need her signature as power of attorney. The patient will have to spend another night in the hospital.

A well-planned transition of care promotes the safe and timely transfer of patients from one setting to the next and helps reduce hospital readmissions, one of the focus areas of value-based care. Too often, the ability to safely and efficiently coordinate care is hindered by inefficient collaboration tools, such as landline phones, fax machines, and email.

By contrast, a powerful care collaboration solution can save time and increase efficiency. For better discharge planning and safer transitions of care, consider these five keys to success:

1. Start planning for discharge at admission.

As hospital stays become shorter, it’s vital to begin discharge planning within 24 hours of admission. Case managers should include patients and their caretakers to ensure their individual goals and preferences don’t get lost in the process. Particularly when a patient is non-verbal, the case manager needs to gather contact information at admission and establish a relationship with a caretaker who has power of attorney. Timely communication with the primary care provider, visiting nurse agency, and facility case manager is also essential when transitioning the patient out of the hospital, so collecting these contacts at admission will help smooth the process later.

2. Improve care coordination with real-time notifications.

When I was a case manager, one of the most common delays was caused by not knowing when a physician had ordered a patient to be discharged. With Backline® from DrFirst, instead of regularly checking the EHR for discharge orders, case managers receive an automatic notification on their tablet or smartphone. This can significantly improve the transfer of information between inpatient and outpatient physicians and standardize discharge instructions. The new CMS mandate requiring ADT notification gives hospitals another incentive to notify care providers automatically when a patient is admitted to or discharged from the hospital or transferred to another facility.

3. Replace phone calls and paper-based processes.

Some hospitals still require case managers to print the patient census at the beginning of each shift to track daily admissions, discharges, and transfers. It’s time to switch from paper-based systems to digital tools so case managers can access real-time clinical information and prevent the costly delays and errors that can lead to avoidable readmissions. With Backline, case managers can use secure, patient-centered text messaging from any location at any time between payers, providers, care teams, non-clinical staff, family members, and even patients. Shifting to HIPAA-compliant messaging helps track all communication around each patient, avoids the hassle of call-backs, and supports working on the go.

Signing of paper documents presents another challenge. Backline lets you send forms electronically, and anyone with a mobile device and SMS messaging can complete, sign, and return them without downloading an app or logging into a portal. That’s important because many primary care physicians, hospices, skilled nursing facilities, and other providers don’t use the same technology as your hospital, and may not want to sign up for additional tools.

4. Keep PHI secure.

Security is essential for any healthcare solution, but when exchanging patient data between facilities and organizations, protecting personal information is particularly critical. If your organization is still using fax machines, telephones, and emails to communicate, you risk exposing patient data, triggering costly fines for your organization, and causing delays in care from missed communication. Backline offers the timeliness of text messaging, plus the security required of HIPAA, the Centers for Medicare & Medicaid Services, and the National Committee for Quality Assurance.

5. Implement solutions that serve multiple purposes.

Nobody needs another siloed solution. With a comprehensive care collaboration platform, hospitals can solve multiple challenges by providing discharge notifications, data transfer capabilities, and a full suite of communication tools, including telehealth, text messaging, and electronic document sharing.

Say a patient receives care at home after leaving the hospital. The visiting nurse can conduct a group telehealth session that brings together the patient, the care team, and a family member. If the nurse sees a pressure injury, he or she can use Backline to send a photo of the wound to the primary care physician. Proactive care like this can go a long way toward preventing readmissions and promoting better patient experiences and outcomes.

Healthcare organizations have no reason to continue using slow, manual processes that hinder care transitions. As the coronavirus pandemic has stressed capacity, emerging models such as virtual care and digital outreach are more important than ever before. Ongoing screening of patients and managing logistics of the vaccine rollout will require efficient processes and digital tools. Case managers (recently lauded as the “unsung heroes” of COVID-19 hospital care) need the best digital tools to streamline workflows; connect providers, payers, and patients; and improve the patient experience while saving health systems the cost of avoidable readmissions.

Backline enables real-time communication between patients, the care team, and all the providers in the care community, whether they are inside or outside the hospital. Used as a desktop client or mobile app, Backline can link everyone involved in the patient’s care. Watch this video tour to see how your hospital can set up case managers for success.


About Rita Patel, RN, BSN
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Rita Patel, RN, BSN, is Director of Program Management, Case Management at DrFirst.