You open your doors, rush in the medically frail, orchestrate a symphony of staff and machines, and do your best to deliver on the promise of the mission statement prominently displayed in your lobby. That should be impressive enough.

But you also conduct this service while complying to an ever-changing barrage of rules and regulations. And don’t forget the quality scores. And the discharge planning.

Now, you are being told to do more with less.

It can all be done picture perfect, which leaves you scratching your head when looking at your avoidable readmission rates and over-utilization days.

One of the many challenges to these issue is that the onus rests with multiple people (patient, doctor, and yes, even you).

We’ve helped determine stress points for many health systems, and through that experience we have observed several recurring themes.

1The discharge process is a vulnerable time for everyone.

Doctors are often worried they will lose their patients to follow up. The health system worries an unprepared patient could bounce back with an otherwise avoidable ailment. And, most important, the patient and family have real anxiety about leaving the security of the hospital and returning to home, where medical care is much farther than a nurse call button.

2The discharge process involves multiple decision makers.

Because of the complexities of the discharge process, health systems are often at the mercy of others to align or approve services before a patient can safely be discharged. This coordination is so complicated, you likely have entire departments in your organization devoted to discharge planning.

3Third parties can compicate matters.

Even after diligent discharge instruction and coordination, things can quickly fall apart when third parties are brought into the mix (such as pharmacy or DME). And when problems are encountered, patients are often left to fend for themselves. Or, as can often happen, they resort to another ED visit.

4An outside support system is crucial.

Even when everything is thoroughly executed, a vulnerable patient with inadequate care support outside your walls is often left with no other safe alternative than to come back to your facility when a medical issue occurs.

So what does this all mean for you?

We don’t promise to fix every operational hurt point of your organization, but we are certainly able to improve the ones we mention above.

By having us assist your system in identifying those patients in greatest need of transition support (be it to home or a post-acute facility), we provide the much-needed safety net that improves efficiency and transparency to an otherwise fragile process.

Because we specialize in coordinating the care needs of the patient and caregiver, we start working before the discharge/transition begins. As we assist your staff in confirming the discharge plan, we establish the rapport with the patient and caregiver that assures continuous support even after the patient returns home. Then, as needed, we continue proactive engagement with the patient. This helps close the communication loop back to your providers and your administrators, all the while enhancing the patient experience and minimizing unnecessary bounce back.

The result? The right care at the right time and the right place.

Happy patient. Happy doctors. Happy hospital.

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