The healthcare system is undergoing a huge shift in the way services are being paid for, and while we haven’t completely made the transition to pay-for-performance, this forthcoming change in payment model means healthcare organizations need to think differently about their patient populations. Whereas they’ve been accustomed to treating patients only when they were ill, now they need to get to a place where they’re keeping patients healthy and out of the hospital. We’re seeing population health management initiatives pop up all over the country aimed at addressing this, but the role of clinical communications in population health management is often overlooked.
A huge part of better managing patient populations is better coordinating the care of those patients, both in and out of the hospitals’ walls, and maybe most importantly, during the patient transitions to the various care settings. In order to do that, hospital-based physicians, nurses, primary care doctors, care managers, post-acute and home health providers, for example, need to be able to communicate with one another about a patient’s health.
Think about when a patient is discharged from the hospital and transitioned to a skilled nursing facility (SNF). In order to keep that patient from returning to the hospital, which could result in readmissions penalties, that patient’s primary hospital doctor, primary care doctor and the SNFist should connect to ensure all teams are on the same page regarding the patient’s care. In many cases, the first challenge is to alert the appropriate providers that their patient was in the hospital in the first place, that the patient is now being discharged, and will be transitioning to a SNF.
With the drive toward population health management, let’s not forget about the importance of communication. We should look at ways to alert the right providers when their patients transition to different care settings, streamline how providers connect with each other, and make it easy for patients to contact their providers. These things are critical for improving care and patient experience, and as an industry, we should be thinking more holistically about clinical communications.
Posted By Jeff Brown