During 2014, hospitals will continue to work toward meeting Meaningful Use guidelines. Nurse case managers may think of Meaningful Use mainly as an information technology (IT) initiative. Yet, some of the goals of Meaningful Use actually tie into the mission to reduce unnecessary readmissions through better discharge planning.
The current trend toward shorter hospital stays means that patients may go home sicker – making discharge planning more important than ever. Case managers have to formulate the best option for post-discharge care, after considering details about the patient’s illness and prognosis, level of health literacy, ability for self-care, and medical needs.
In the past, case managers have gathered, organized, and disseminated the information needed for a smooth discharge through manual processes. This is starting to change, as EMR vendors begin to include discharge planning modules in their software packages. By processing discharge data more efficiently, case managers can further specific Meaningful Use goals and help reduce fragmentation of care. There are four key elements of discharge planning that may be supported or optimized by technology, and each is discussed below.
- Transition Planning. This basic function is necessary to ensure continuity of care and the right level of post-discharge services. When a patient will be discharged to another facility, it can be time-consuming to find an appropriate match and make inquiries about available beds and services. Software known as patient placement systems (PPS) – or, alternatively, as discharge referral systems (DRS) – can speed up the process by allowing case managers to electronically search facilities on a regional level and to make secure, paperless referral inquiries online rather than sending and waiting for faxes. These systems can also make it easier for case managers to track and monitor the status of multiple patients in real time.
- Medication Reconciliation. Stage Two of Meaningful Use guidelines state that participating hospitals must electronically perform medication reconciliation for 65 percent of patients making a transition of care. It is hoped that an automated process will address this crucial step more accurately and efficiently than comparing the pre- and post-discharge medication lists by hand. Software designed for this purpose integrates with pharmacy systems and computerized provider order entry (CPOE) systems to help ensure that no medications or dosage changes have been missed.
- Patient and Caregiver Instructions. An important requirement of Meaningful Use is that providers “use certified EMR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.” Since clear, comprehensible discharge instructions can help a patient avoid complications at home, providers are looking for ways to easily create personalized discharge documents tailored not only to the patient’s medical needs, but to his level of health literacy as well. Technology vendors are responding to this need by providing document libraries that integrate with the EMR and make it fast and easy for providers to create individualized discharge instructions – without reinventing the wheel each time.
- Discharge Summary. This document often serves as the primary means of communication between hospitalists and primary care providers – and research shows that when getting it to the patient’s primary care doctor quickly can decrease the chance of an unnecessary readmission, while increasing the likelihood the patient will receive timely follow-up care. Meaningful Use does not actually require an electronically generated discharge summary. Yet, some technology vendors are offering an optional module to improve the flow of key information. The discharging physician can complete a user-friendly template that standardizes the discharge summary with the most important information at the top – including the outcome of hospitalization, follow-up care needed, and plans for additional services (hospice, home health aides, patient monitoring devices, etc.) Where case managers are expected to make follow-up calls or set follow-up appointments, an automated work queue could help them manage tasks and track patient status.