From the first bedside conversation to the final bill out the door, when identifying referral patterns and types of patients needed to further clinical education, the cycle of the care journey has gaps that can be bridged by interoperability.
Home health and hospice organizations have seen a distinct shift in referral mixes, as well as acuity levels, throughout the pandemic. Physicians who were previously more inclined to refer to a facility setting are now embracing patients receiving the care that is needed in the home setting. Hospital referrals to the home health segment also increased. We saw a decrease of referrals to skilled nursing in some markets at around 35-40%, meaning the acuity and complexity of patients being cared for in the home has shifted.
A continued focus for organizations begins with the initial family and patient conversation. Business development teams can help drive the strategy of care in the home with smooth care coordination by capturing patients earlier within their care journey, with each step made easier through interoperability.
Why the Need for More Interoperability?
When looking at the patient population being served by home health in 2020, 10% of the home health primary diagnoses were COVID-19, with other diagnoses ranging from kidney disease, heart, respiratory and cancer within the hospice service line.
It is no surprise that one in four Americans suffer from multiple chronic conditions that are having to be managed. This is requiring organizations to become even more specialized to address the acuity of their patient population, accomplished by investing in technology, integration, talent and education.
With the increasing demand for complex care in the home, interoperability will drive efficiency, lower expenses, administrative costs, eliminate duplication of document errors and can reduce the strain on staffing.
Steps to Improve Care Coordination Through Interoperability
Utilize your technology partners (healthcare software, customer relationship management software) to review and analyze any existing referral trends: attending physicians associated with patients, diagnosis patterns and diagnosis timeliness of referrals. To really accelerate growth, your call frequencies to referral partners should focus on diversification; do not rely on the same hospitals and skilled nursing facilities. Remember – where you spend your time, you will see results.
The process of quickly accepting new referrals and beginning intake should be structured and planned. Consider how your organization will take in referrals on the evenings and weekends, in addition to the traditional workweek. Do you have the ability to assess any capacity issues in real time, as they happen? Research how your electronic medical record (EMR) software and interoperability partnerships can aid in the speed and ease of use for the intake process. To be able to provide the right level of care at the right time, access to care is crucial. Interoperability features, like a staffing and scheduling platform, can solve staffing scarcity and be especially helpful with last-minute referrals.
Communication of the care journey is crucial in coordinating care. Seek an EMR technology that provides many service lines and enables easy transitions of care from one level to another, like home health to palliative and hospice care. Giving your patients and their families the ability to communicate with attending physicians and medical professionals through a family portal can prevent confusion, while improving quality and coordination of care delivery and is loved by both the patients and their family members. There are also integration partners that provide telehealth and telemedicine capabilities, made vital during the public health emergency.
Predictive analytics is an important tool and can be useful when studying referrals, as well as providing excellent care in general. There are innovation features that will improve efficiency and reduce redundant demographic and medication-related entries, while also reducing reconciliation errors. Your integration partner can provide predictive analytics of when to refer patients to the right level of care at the right time. This will also help leaders gain insight on referral, admission and not taken under care patterns to optimize their growth and care delivery opportunities.
Clinical intelligence, providing education on care and how to properly document the care given, will drive coordination, leading to improved patient outcomes, fewer compliance issues and a decrease on denied claims. An intuitive EMR can help with this, with built-in compliance features, like required documentation to start the care, an Outcome and Assessment Information Set (OASIS) scrubber and secure messaging features to request and receive orders needed to bill for services.
Interoperability is only half of the formula for providing excellent care. Keep in mind that making the referral, receiving the referral, a timely response to the referral and a smooth care coordination from one level of care to the next should all begin with the patient in the center and only happen at the right time for them.
Axxess, a cloud-based care at home software, provides HIPAA-compliant solutions for home health, home care, hospice and palliative care professionals with useful interoperability features built in.
