Gap in Care Quality during the Discharge Process for Care Coordination for Patients with Chronic Illnesses
Patients in the United States who experience long-term illnesses may change from one health care setting to another. They might move from home to a hospital, to an assisted living facility, or to other types of residential care. The coordination of care for patients with chronic illnesses is reliant on the abilities of health care providers to interact effectively in order to provide optimum outcomes (NTCC, 2010). In order to determine the best possible option for the patient, care coordinators must accurately assess the patient’s condition, reach a consensus on prognosis, evaluate possible resources, and develop and initiate a care plan. The numbers of patients suffering from long-term illness continue to rise as health care technology improves; therefore, the need for efficient and effective care coordination has become more essential for the general population. However, there is a gap that exists within healthcare delivery systems during the discharge process that requires evaluation and solutions.
In the United States, it is expected that by 2023 the population of citizens over the age of 65 will reach 61.4 million people, or about 18 percent of the total number of Americans in the country; this statistic reflects an increase of 16.7 million people over the decade from 2013 (U. S. Census Bureau, 2014). The continuing growth of the population of the elderly places mounting pressure on health care delivery systems as approximately 70 percent suffer from acute illnesses (Chen et al., 2013). The subsequent rise in healthcare expenditures and quality of patient care has placed additional importance on discharge planning (Mendez de Leon & Stroot, 2013). Many times, patients with chronic illnesses are released from hospital care with complicated co-morbidities and high vulnerability related to stress, placing them at enhanced risk of poor health outcomes (Daly et al., 2017; LeBlanc, Guise, Gosselin, & Feyz, 2006). A smooth transition from the hospital to other healthcare settings focuses on promoting optimum outcomes.
The process of developing and implementing an effective discharge plan relies on the nursing process of assessment, planning, implementation, and evaluation (Wang, Zhao, & Zang, 2014). There are a number of teams that are required to cooperate in discharge planning for chronically ill patients including the primary team, the community team, and the resource team. The primary team is a group of health care providers who interact to access future needs of the patient, create a care plan to promote optimum functioning, and implement the care plan. The resource teams consult with the primary team and provide recommendations, education, and assistance with discharge plan implementation. The community team is comprised of the agencies and programs within the patient’s community and assists in implementing the discharge plan. The discharge plan must include patient education from all the teams concerning continuing care in the future setting. Knowledge about their illness allows patients to be counseling in ways to modify behavior and manage their next step in care. Evaluation of the discharge plan determines of the established needs are satisfactorily met from follow-up with the patient, family, community agencies, and facility.
Unfortunately, a gap exists in effective discharge planning for the chronically ill patient due to fragmented communication between discharge teams and multiple healthcare providers secondary to being pressed for time. A survey by the Agency for Healthcare Research and Quality (AHRQ) reported that in 42 percent of the hospital responding, items were not addressed during the transition from the hospital to another healthcare setting and there were frequently problems in communication (AHRQ, 2007). Poor communication during transition promotes confusion and may result in duplicated tests, inefficient monitoring of patient status, errors in medication, delayed diagnosis, and unscheduled referrals (NTCC, 2010). The result is a threat to patient safety and quality of care. The healthcare delivery system incurs unnecessary costs and patient and family dissatisfaction.
A study by Forster, Murff, Peterson, Gandhi, and Bates (2003) concluded that one out of every five American patients discharged home after a hospital admission reported an adverse event within the next three weeks; medications were responsible for 60 percent of the incidences and were determined to be avoidable. When Medicare fee-for-service beneficiaries were discharged, 19.6 percent returned to hospital care within one month and another 34 percent within three months (Jencks, Williams, & Coleman, 2009). The hospital readmission with one month of discharge placed a burden of $15 billion on the Medicare program (Medicare Payment Advisory Commission, 2007). In response, organizations have been created to address reducing the number of adverse events after hospital discharge and improving the process of transitional care. The mission of one such organization, the National Transitions of Care Coalition (NTOCC), is to increase awareness of the importance of transitional care among healthcare providers, government officials, patients, and their families (NOTCC, 2017). By utilizing the recommendations of healthcare experts, the organization has developed tools and resources to assist healthcare providers to create a seamless transition from one care setting to another.
There are a number of initiatives taking place dedicated to addressing the gap in during the discharge process for care coordination for patients with chronic illnesses. For instance, healthcare providers are not reimbursed for the time spent in coordinating transitional care in a system that is based on fee-for-service. In order to generate revenue, the hospital strives to fill empty patient beds, discouraging discharges. Public and private payers have become more aware of the situation and many are testing incentives for hospitals that provide compensation for coordination of transitional care from the hospital setting. In Section 3026 of the Affordable Care Act of 2010, the Community-Based Care Transitions Program was established (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). From 2011-1015, the program provided $500 million to systems and organizations that provided at least one intervention for the transition of care to Medicare patients determined to be high-risk. The interventions might include services starting within 24 hours before patient discharge from the hospital, rapid follow-up services after hospital discharge, attention to promoting interactions between the transitional healthcare setting and the patient and family, and review of medications. The Center for Medicare and Medicaid Innovation (Section 3021) also allocated $10 billion for 2011-2019 for development of innovative care models that included those for transitional care. The Federal Coordinated Health Care Office (Section 2602) is dedicated to ensuring safe care transitions for patient who are eligible for both Medicare and Medicaid.
A discussion of one initiative for transitional care highlights the problems and potential successes programs of this type encounter. A study was conducted by Logue & Drag ( 2013) evaluating the effectiveness of the Community-Based Care Transitions Program. The researchers followed 149 patients from an Arizona retirement community as they transitioned from hospital care to other settings. Patients expressed high degrees of satisfaction with the transition program. Regarding follow-up appointments prior to discharge, 98.5 percent were scheduled. During a medication review, nurses found approximately 300 discrepancies. It was expected that 22 patients would be admitted within 30 days of discharge, but only 6 patients (4 percent) were readmitted; this far exceeded the goal set by Medicare of 20 percent. It was estimated that the savings to the Medicare program over the nine months of the study was $321,288. Problems with the process included omission in documentation, which may be corrected with adequate staff training and supervision. The omissions concerned screenings for depression and mobility and medications. The nurses claimed the documentation tool used Word-formatting, which was tedious to use. Alternative documentation processes may improve compliance. However, the change to a Web-based case management software program with drop-boxes and other time-conserving options exacerbated the lack of documentation because the nurse was required to scour each patient file for specific measures of program outcomes. There are some legal issues inherent in the collaboration of providers during the course of transitional care (Chouteau & Crowe, 2013). For instance, regulations imposed by the health Insurance Portability and Accountability Act (HIPAA) protect access to health care information by outside agencies. Care coordination is heavily dependent on sharing information through technology and HIPAA regulations allow practice with formal consent. However, some states have more stringent policies concerning sharing healthcare information than HIPAA and this may cause problems with access for some coordinators. Another barrier may be the fact that nurses supplied by the hospital are required in readmission to hospitals and the federal Anti-Kickback Statutes and possibly even the Start Law may come into effect if the hospital is the source of the referral for the nursing facility; the Department of Health and Human Services has identified five waivers for the problem. Finally, federal antitrust laws may implicate competitors that negotiate reimbursement involved in transitional care arrangements.
In conclusion, the goal of establishing processes, coordination of care, effective communication and documentation, and interactions between transitional teams is not unrealistic for a smooth change from a hospital care setting to another healthcare setting. A number of agencies and organizations are committed to the development of tools for assessments of patients and other aspects of transitional care in order to promote standardization for compliance. Further research is necessary, but advances are being made toward creating the best possible health outcomes by closing the gap in care quality in discharging patients with chronic illnesses from hospitals to another care setting.
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