1. How can we improve post-discharge transition support to set patients up for success in primary care?
Although smoothing care transitions has long been a priority for population health leaders, it remains an enduring challenge. That's in part because there's no easy substitute for a well-planned, in-depth care coordination strategy. Progressive organizations look beyond the 30-day post-discharge window to stabilize patients in primary care for the long term.
Use these five strategies to build an advanced care transitions approach:
- Identify patients most likely to be readmitted with an initial assessment on admission
To most effectively allocate resources, sort patients into low, moderate, and high readmission-risk categories to determine care plan next steps. Low-risk patients require a routine discharge, whereas moderate- or high-risk patients will need additional transitions support tailored to their specific risk drivers.
- Identify readmission risk drivers for moderate- or high-risk patients with in-depth assessment
For patients who require additional transitions support, conduct a more in-depth assessment at bedside including psychosocial indicators. Additional insight into major readmission drivers informs the post-discharge care plan.
- Determine next care site and whether a home visit is required
Due to the resource requirements needed for home visits, reserve this post-discharge support for highest-need patients. For moderate-need patients, be sure to define clear points of contact at next sites of care (e.g., PAC, primary care) and set patients up for success with an initial round of self-management education.
- Automate care team's workflow to standardize the transitions process
Initiate a discharge planning conference for highest-need patients that includes the inpatient team lead, transitions lead (e.g., navigator, ambulatory care manager, PAC provider), patient, and caregiver. An inclusive conversation ensures care plan information transfers to the next care team lead and encourages active participation from both the patient and caregiver.
- Meet clinical needs, overcome non-clinical barriers, and support self-management to bridge the hospital-primary care gap with a warm handoff
Prior to discharge, the transitions lead should understand the major barriers to clinical stabilization and set a strategy for meeting patients’ clinical, non-clinical, and self-management needs. In addition, the lead should have a clear main point of contact in the ambulatory setting to continue in-depth support. High-risk patients may benefit from post-discharge calls to ensure the primary care team is meeting their full range of needs.
2. What is the value of annual wellness visits in population health?
Annual wellness visits (AWVs) pose an opportunity for the care team to prevent patient escalation. These visits can help unearth clinical and non-clinical needs that factor into care decisions. Primary care teams should proactively schedule AWVs with less engaged and at-risk patients to regularly collect clinical and psychosocial data that inform risk stratification. AWVs are reimbursed for providers and free of cost to patients, encouraging more frequent preventive care and driving patient satisfaction. In addition, these annual visits can be a good opportunity to bring up advance care planning, another reimbursable current procedural terminology (CPT) code with significant potential downstream savings.
Want to learn about emerging trends and innovation in population health? If you missed our January 31st webinar on the Care Transformation State of the Union, you can grab the slides or listen to the webconference recording today.