How IT can help support patient engagement after discharge

Until fairly recently, patient engagement was not a business imperative for hospitals. The importance of patient engagement has increased primarily because of two changes in the way Medicare pays healthcare providers—the advent of readmission penalties and the transition to value-based reimbursement.

These changes have created a strong inducement for hospitals and health systems to get patients involved in their own care. Unless more patients make a real effort to adhere to care plans and learn how to manage their own conditions after discharge, there’s little chance that healthcare providers and accountable care organizations (ACOs) will cut costs enough to succeed under value-based reimbursement.

Efforts to engage patients can and should continue after discharge. Transitions in care hold the key to preventing readmissions and to ensuring that patients’ health conditions are properly managed in settings such as a post-acute or long-term care facility.

Interactive patient systems (IPS) currently provide education, entertainment, Internet connections and a range of other patient services in hospitals. These platforms enable patients and families to take a more active role in the care process by using familiar devices and methods of engagement to teach them about their health conditions and treatment options.

For example, IPS solutions educate patients about post-surgical recovery and dozens of chronic conditions, such as chronic heart failure and asthma, by watching assigned videos prescribed by caregivers. Inpatient solutions are designed to provide connections, initial guidance and direction. However, evidence suggests patients and families are only able to consume limited information while in the hospital, especially during the discharge process itself. Lowering the cost curve will require continued access to healthcare professionals and information after discharge.

Just as discharge planners begin collecting information from patients when they’re admitted and help prepare patients for discharge, an IPS platform can inform patients during the acute care experience, prepare patients for the journey home or to a post-acute-care facility and continue to provide access to resources post discharge. IPS platforms are designed to provide information and reinforcement, assess understanding, ensure patients are on the path to improved quality of life and provide additional access to resources. Patients can use IPS not only to receive educational materials tailored to their conditions, but they can also complete IPS surveys that show how motivated and able they are to care for themselves, both during and after their hospitalization.

Discharge instructions are complex and often difficult to understand, resulting in failure or inability to make follow-up appointments, obtain or properly administer necessary medication and conduct important self-checks, which are leading indicators of potential concerns that can cause unnecessary readmissions. Assisting patients to understand and apply post discharge instructions by incorporating IPS can decrease the likelihood that they will be readmitted.

Post-discharge patient engagement
Post-discharge instructions, including guidance on how to take medications, are often complex. When patients have the knowledge, skill and confidence to manage their own health, they can perform these tasks more easily. It is not easy to activate patients for a variety of reasons including, readiness to engage, lack confidence and other social determinants of health. In addition, patients may have low health literacy, contributing to difficulty understanding and applying health information.

While not every patient can be fully engaged, it is possible to measure the extent to which a person can become involved to manage their own care. Several instruments have been developed for this purpose, including the Person Engagement Index, an 18-question survey used in conjunction with one IPS solution. This validated survey assesses a patient’s capacity to be engaged in four domains, including their overall ability to engage, how proactive they are, their ability to use technology and their psychosocial support. The overall score and scores from each domain are supplied to clinicians.

Drawing upon this engagement data and their own clinical assessments, the provider and the patient can jointly create a post-discharge plan that reflects that person’s specific needs, preferences and resources. With continuing support from the hospital, the patient is more likely to understand and adhere to his or her care plan, increasing the likelihood of an optimal outcome.

Supporting technology
Mobile apps for smartphones and tablets can be used to expand IPS solutions beyond the hospital walls. These apps are connected to the IPS platform and to the clinical information in the EHR via the hospital’s patient portal. Patients can use these apps to receive educational materials on procedures, conditions and medications that their physicians have prescribed. In addition, automated reminders and care tips can be sent to patients to promote their compliance with care plans. Patients also can use the app to view and download the medical information and educational materials from their hospital stay.

Care teams can use these mobile apps to monitor post-discharge progress and to prioritize patient outreach based on health risks. Providers can receive automated alerts when critical action items are not completed on time. Care managers can identify patients who need help and individualize the care plan and interventions as needed.

IPS solutions can also be integrated with telehealth software to create a virtual visit with a patient. Supported by the educational content and the engagement survey results in the IPS, the physician can interact with the patient to fine-tune the care plan and engage the person more fully in self-management.

IPS technology can help providers, care teams and discharge planners continuously engage patients from the time they enter the hospital through their transition to the next stage of care. The ability to educate, support, and engage patients throughout their care journey can help hospitals provide better, individualized care and thrive under value-based reimbursement.