Deliver a Quality-Driven Patient Experience for Polychronic Patients

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To deliver a quality-driven experience for polychronic patients, physicians must proactively identify chronically ill patients and their needs—and match them to tailored interventions. Through our research, we identified two strategies that hospitals and health systems can use to uncover and better address polychronic patients’ needs in the inpatient setting.

Five tactics to improve quality and patient experience for polychronic patients

Executive Summary (p. 4): Redefining the patient experience ambition

Strategy 1: Use action-oriented screenings to address overlooked barriers to care
Proactively screen polychronic patients for commonly overlooked clinical and non-clinical risk factors and consistently link patients to tailored support during and after the inpatient stay.

• Mortality risk screen (p. 8): Identify patients who are at risk of 30-day mortality at the decision to admit and match them to a standardized set of clinical interventions.

      Related resources:
      Published studies on the mortality risk screen
      St. Joseph Mercy's mortality risk screen care bundles and interventions
      Additional evidence to quantify the value of a mortality risk screen

• Patient Activation Measure (PAM) (p. 13): Measure patient activation—a patient’s underlying knowledge, skills, and confidence to manage their health—to inform their care plan.

      Related resources:
      Insignia’s Patient Activation Measure questionnaire
      Additional evidence to quantify the value of the PAM

• Health system gold card (p. 17): Develop a comprehensive, cross-continuum program to support patients with a specific chronic condition and high inpatient utilization.

      Related resource: Additional evidence to quantify the value of a health system gold card

Strategy 2: Extend acute care services beyond the inpatient setting  
Shift acute care services to patients’ homes to help reduce readmission rates and improve experience.  

• Flipped Discharge (p. 22): Move elements of the discharge process from the hospital to the home setting to decrease length of stay and improve patient satisfaction.

      Related resource: Additional evidence to quantify the value of flipped discharge

• Hospital at home (p. 27): Provide comprehensive, inpatient-level care in patients’ homes to avoid hospital stays altogether.

      Related resource: Additional evidence to quantify the value of hospital at home