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Live from HFMA: Automating the Care Transition Process

June 25, 2014
by John DeGaspari
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Finding the appropriate post-acute facility for patients at discharge

At the time of patient discharge from a hospital, managing the transfer of the patient to an appropriate post-acute care facility in a timely fashion can be a challenge, both for the provider organization as well as for the patient and his or her family. About three years ago, the University of Iowa Hospitals and Clinics, which includes a 705-bed hospital in Iowa City, decided to automate what had been a manual process, implementing a solution provided by Ensocare (the hospital is also a development partner with the vendor). The vendor also backs its solution with a call center to help the care transition process run smoothly.

Joshua Brewster, director of the Department of Social Services for the hospital system, says a typical caseload for a discharge coordinator there is from 20 to 30 patients; of those, five to 10 have significant needs at the time of discharge. For most of the patients, the discharge is a relatively straightforward affair: the caseworker reaches out to one or two post-acute facilities that the patient has identified as their preference. Patients with more challenging needs—those with co-morbidities, psycho-social issues, legal difficulties, or the recently incarcerated, for example—can be difficult to place, Brewster says.

In either case, but especially with those with greater needs, manual discharge procedures can be a time-consuming affair of faxing, long waits for responses, and playing  telephone-tag with potential post-acute facilities.

Automating the system has smoothed the care transition process significantly, Brewster says. “It’s a couple of clicks instead of printing out what you need to send, faxing it out, following it up with a phone call, paging and doing a lot of back and forth,” he says. He adds that in terms of staffing, automating the process has freed up full-time employees for other tasks.

The automated system notifies the hospital that its information has been received by the post-acute care facility, which is considering the case. Often decisions can be had within a 30-minute turnaround, he says. “We are not going to make as many phone calls, if at all. We have discharges where we don’t have to talk to the receiving facility. We have no standing by the fax machine so we are not tied to an office. We can be out on the unit, because [the solution] is Web-based,” he says.

Handling the straightforward discharges more quickly gives caseworkers more time to handle more challenging cases. If a patient stays in the hospital past his or her expected length of stay, “We know what we’ve done in terms of the handoff to the place and we make those referrals, Whereas in the past it would have been someone making a lot of phone calls and a lot of faxes,” he says

The University of Iowa health system serves a large geographic area, and Brewster says the health system strives to make a good fit between the patient and the post-acute facility, which means aligning the patients medical needs and, often, proximity to the patient’s family as well. He adds that the search for a facility is quite granular, taking into account the patient’s dietary needs or the facility’s ability to care for Alzheimer patients. Wayne Sensor, CEO of Ensocare, notes that the vendor maintains a database with 100,000 post-acute providers.

The care team led by Brewster has expressed a strong interest in having the Ensocare software interface with the University of Iowa health system’s (Epic) electronic health record (EHR), which it is now in the process of doing. In addition, the vendor is finalizing a linkage with the Cerner EHR, and will continue to interface with all major EHR vendors, which enables a single sign-on and workflow, according to Sensor.