Care Coordination With Agencies: Reducing Readmissions, Enhancing Patient Care

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In addition to the healthcare providers’ moral and professional  obligations  to patients and their families to provide the best coordination of care both in the hospital and through the discharge process, CMS’s Hospital Readmission Reduction Program (HRRP) has provided  powerful  financial incentives – in the form of penalties – to bring down the rate of re-admissions. A pivotal piece of that is establishing an effective plan of care at home as quickly as feasible. Multiple aspects of this plan may include relationships between an agency and hospital social worker discharge planner, person of contact at the agency coordinating care, possible rehabilitation facility stay, and cli ent physician interaction with the agency/ plan of care and executing the plan of care in the home environment.

TEAMWORK: KNOW YOUR AGENCIES AND THEIR ROLE

It is critically  important  that the hospital social worker discharge planner has a list of agencies which have been pre-researched and have demonstrated the ability to manage care in post-hospital settings. The agency must be proactive in establishing the relationship with discharge  planners at individual  hospitals, rehabilitation facilities, physician offices and outpatient surgical offices, with information regarding agency expertise. The hospital or the family will contact an agency to coordinate patient care. Discharge planners and doctors  must be educated  as to the capabilities of a specific agency, prior to selecting that agency to provide necessary care.

The  agency should be involved in patient case management meetings at the hospital prior to discharge.

“IT IS THE PATIENT’S RIGHT TO HAVE AN ADVOCATE
ATTEND  ALL CASE MANAGEMENT MEETINGS AS THEIR REPRESENTATIVE.”

When a patient is in a rehabilitation facility, it is very important that a point person from the agency be appointed  to attend all case management/progress meetings at the rehab to present and resolve any issues, discuss client progress with physical therapy, occupational therapy, medical/ medicine management and ultimate release to the home environment.

POST DISCHARGE: HEADING OFF POTENTIAL MEDICAL PROBLEMS

By attending all patient management meetings and acting as the patient advocate at the rehabilitation facility, the agency point person will often head off potential medical problems, monitoring rehabilitation therapy progress, preventing the occurrence of institutional psychosis and planning the return to the home environment. It is the patient’s right to have an advocate attend all case management meetings as their representative.

For example, when the patient has completed his or her regimen of physical therapy at rehabilitation (or completed as much of the therapy as physically possible) it’s time to consider returning to the home environment. The agency point-person will follow-up appointments, which are critical in reducing re-admissions. The agency point person will have overall case management skills, to ensure that medical and quality of life goals are being met in the home and that any issues are being addressed immediately to prevent hospital readmission.

PATIENT STATE OF MIND  AND SUSTAINED RECOVERY

Patient well-being  and state of mind is an important factor in care management. The agency point person will make every attempt to inform family members (whether local or distant) of the patient’s progress. They make a faster and sustained recovery when caring family and friends are involved. Most patients make a better sustained  recovery when living in their own home. The coordination of medical resources, problem resolution, aides to assist home living, and an advocate assisting with day-to-day living all create piece of mind and confidence living in the home. It all begins in advance of the discharge where the continuity of care begins, and supports the best outcomes.

Therefore, the agency needs be proactive when establishing patient care management and have input into helping help establish the projected  release date, coordinate transportation  home, obtain/ setup durable medical equipment, institute medicine management,  schedule doctor/ nurse/home therapy personnel visiting the residence (if the patient is non-ambulatory) and place permanent or temporary aides to assist in the home as necessary. Depending on the ambulation  of the patient, aides will be utilized to transport the client to select a rehabilitation facility if the medical plan dictates such care is necessary. Agencies often have valuable insights into the capabilities  and effectiveness  of individual rehabilitation facilities.

Elaine Cohen is the founder and president of Advocates on Call, a new agency providing senior care services. Elaine’s expertise includes  human resources, financial consulting, senior case management, small business administration and staffing, focusing on communication and being a resource to the patients and their families.

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