Until fairly recently, patient engagement was not a business imperative for hospitals. The importance of patient engagement has increased primarily because of two changes in the way Medicare pays healthcare providers—the advent of readmission penalties and the transition to value-based reimbursement.
These changes have created a strong inducement for hospitals and health systems to get patients involved in their own care. Unless more patients make a real effort to adhere to care plans and learn how to manage their own conditions after discharge, there’s little chance that healthcare providers and accountable care organizations (ACOs) will cut costs enough to succeed under value-based reimbursement.
Efforts to engage patients can and should continue after discharge. Transitions in care hold the key to preventing readmissions and to ensuring that patients’ health conditions are properly managed in settings such as a post-acute or long-term care facility.
Health and medication management systems provide education, entertainment, Internet connections and a range of other patient services in hospitals. These platforms enable patients and families to take a more active role in the care process by using familiar devices and methods of engagement to teach them about their health conditions and treatment options.
Discharge instructions are complex and often difficult to understand, resulting in failure or inability to make follow-up appointments, obtain or properly administer necessary medication and conduct important self-checks, which are leading indicators of potential concerns that can cause unnecessary readmissions. Assisting patients to understand and apply post discharge instructions by incorporating health and medication management systems can decrease the likelihood that they will be readmitted.
Post-discharge patient engagement
Post-discharge instructions, including guidance on how to take medications, are often complex. When patients have the knowledge, skill and confidence to manage their own health, they can perform these tasks more easily. It is not easy to activate patients for a variety of reasons including, readiness to engage, lack confidence and other social determinants of health. In addition, patients may have low health literacy, contributing to difficulty understanding and applying health information.
While not every patient can be fully engaged, it is possible to measure the extent to which a person can become involved to manage their own care. Several instruments have been developed for this purpose such as post-discharge surveys. Surveys can assess a patient’s capacity to be engaged.
Drawing upon this engagement data and their own clinical assessments, the provider and the patient can jointly create a post-discharge plan that reflects that person’s specific needs, preferences and resources. With continuing support from the hospital, the patient is more likely to understand and adhere to his or her care plan and medications, increasing the likelihood of an optimal outcome.
Mobile apps for smartphones and tablets can be used to expand health and medication management systems beyond the hospital walls. Patients can use these apps to receive educational materials on procedures, conditions and medications that their physicians have prescribed. In addition, automated reminders and care tips can be sent to patients to promote their compliance with care plans and medications.
Care teams can use these mobile apps to monitor post-discharge progress and to prioritize patient outreach based on health risks. Providers can receive automated alerts when critical action items like prescribed doses are not completed on time. Care managers can identify patients who need help and individualize the care plan and interventions as needed.
Health and medication management systems can help providers, care teams and discharge planners continuously engage patients from the time they enter the hospital through their transition to the next stage of care. The ability to educate, support, and engage patients throughout their care journey can help hospitals provide better, individualized care and thrive under value-based reimbursement.