Even a team of all-stars won’t win if its players can’t get on the same page.
This is the situation with patient care transitions today, as all parties involved – payers, providers, physician cohorts – have generally focused on improving their role in the process, but not developed larger strategies involving multiple stakeholders.
The consequences of continuing in this way are only growing more serious as the cost of care continues to rise, short-handed staffs grapple with more complex medical and administrative decisions, and government regulations create very different priorities for each entity. Even more sobering is a statistic included in a Forcura-sponsored study, which shows more than 44% of participants acknowledge that poorly managed care transitions have had a very negative or extremely negative impact on their patients.
So, what will it take to improve patient care transitions? This is what panelists in Forcura’s recent CONNECT webinar, “How To Drive Smart Care Transitions & Transform Patient Care,” sought to answer.
A Meeting of the Minds
Just as Forcura has previously brought together various voices in the home-based care industry, this webinar featured representatives from Kaiser Permanente, Permanente Medicine, and Reliant at Home. Building relationships to achieve alignment was a central theme, as the panel discussed how healthcare organizations will only start moving the needle on care transitions when they purposely and consistently reach out to understand each other’s priorities in detail and what gaps in understanding may exist.
“I would challenge us as an industry … to move upstream and understand what's happening all along the way,” Bill Gammie, senior director of post-acute utilization at Kaiser Permanente, said.
Learning Along the Way
Alignment requires educating all parties involved, added Sandeep Sankineni, MD, director of advanced care at home at Permanente Medicine, and it is an ongoing commitment.
“It is by far the biggest thing that I've found is a challenge, which is just education around what can our home care agencies do?” he said. “What are they comfortable with? What should we hold [each other] accountable for? … What [are expectations for] the end outcome for the patient?”
Jana Lightfoot, COO of Reliant at Home, agreed and explained that as primarily downstream care providers, the home-based care sector must connect better with referral sources and payers – particularly those offering Medicare Advantage (MA) - to not only share their concerns but to sometimes modify their own traditional ways of approaching care.
“I think a challenge on [our] side of the fence is to think about care much differently and operate in a way that's much more favorable to payer sources,” she said. “That's what we're [as an industry] trying to get to, so if we can have those conversations more often, I think we can find a faster path to making [processes] much more successful.”
She added that flexibility can also be a challenge when home-based care agencies are constrained by regulatory requirements, for example needing to complete an entire OASIS when all the patient might require is a quick blood draw. If home-based care organizations need to be nimble to satisfy what MA payers require for their members, then federal policymakers must consider how their regulations can be revised to grant that level of partnership.
Technology That Enables Alignment
Acknowledging healthcare technology’s role in facilitating smoother care transitions, moderator and COO of Forcura Annie Erstling mentioned new, AI-driven enhancements to the company’s referral management technology as an example of how home-based care agencies can be empowered to quickly make smarter referral decisions. This has the added benefit of making agencies even easier for referral sources to work with while facilitating stronger interactions between various healthcare entities overall.
“I think our perspective is it's people and it's process and programs that you put in place, and then technology can really be the enabler,” she said. “And technology is a requirement today, obviously, to be able to manage the complexity of this [issue].”
These are just a few of the insights offered during this information-packed event. To learn more, access the recording today.
