A patient's healthcare journey begins at the front desk but doesn't conclude there. Instead, it extends through various touchpoints of care, especially during transitions between different healthcare providers and the pivotal moment of discharge. This juncture, often accompanied by complexities and uncertainties such as managing follow-up appointments, drug regimens, and behavior changes, largely falls on the patient and can significantly impact their well-being, satisfaction, and outcomes.
However, healthcare providers can ensure a smooth transition and support their patients through these challenges.
Let's understand why patient engagement is key during the transition of care (ToC) and uncover ways to improve patient experience for better patient outcomes.
Research shows that one in five patients experiences an adverse event after being discharged from the hospital, and 49% experience medical errors related to care discontinuity between in-patient and out-patient settings. The gap in patient care during transition of care (ToC) subsequently increases the risk of rehospitalization.
While the gap in care impacts patients' health outcomes, it also adversely affects healthcare providers. Medical practices may face financial penalties for high hospital readmission rates. Additionally, readmissions result in heightened resource utilization, driving up expenses and negatively impacting practice performance.
One of the primary challenges in care transition is ensuring your patient adheres to the post-discharge recommendations, which often arises because the instructions aren't clear and comprehensive enough.
A study on the association between readmissions and health IT adoption revealed that improved patient engagement during ToC played a vital role in lowering hospital readmission rates.
When patients can view their health information, they comprehend their discharge instructions and medications in a better way, improving medication adherence and outcomes. Moreover, this enables them to make informed decisions about their care, stick to their treatment plan, and take a more active role in their healthcare decisions.
Delivering excellent healthcare services for in-patients may seem straightforward. However, maintaining care continuation during care transition and ensuring adherence to discharge recommendations is
a distinct challenge.
Effective and continuous patient care isn't possible without the collaborative effort of patients and their clinicians. Here are six ways to improve patient engagement and experience during ToC:
One of the main hurdles during ToC between different healthcare providers is the lack of access to complete patient information. Electronic Health Records (EHR) interoperability enables clinicians to access vital patient health data, preventing unnecessary duplication of tests, reducing wait times, and ensuring a smoother care coordination process.
On the other hand, a clear and comprehensive discharge summary and recommendations enable patients to understand their post-discharge care instructions, follow-up appointments, and medication regimens more effectively. Taking control of their health and adhering to treatment plans becomes easy, leading to improved health outcomes.
Patient Portals provide access to lab records, discharge summaries, medication lists, and care plans, empowering them to play an active role in their health-related decisions. When patients are engaged in their healthcare journey, it leads to a profound sense of satisfaction and ultimately results in better clinical outcomes.
As patients take a more active role in their healthcare journey, it's natural for doubts and questions to arise. Offering real-time communication channels, such as direct messaging with their healthcare provider or chatbots to address their concerns automatically, instills confidence, particularly during transitions of care (ToC). This proactive approach helps prevent adverse outcomes and ensures patients feel supported and informed throughout their healthcare journey.
Remote Patient Monitoring (RPM) enables healthcare providers to continuously monitor their patient's vital signs, symptoms, and health metrics, providing a level of care similar to in-patient settings but from the comfort of patients' homes. This alleviates the stress of independently managing one's health and fosters a sense of satisfaction and care among patients. Additionally, RPM offers timely insights into patients' health status, facilitating early detection of complications or changes in condition, thereby reducing the risk of readmissions.
Follow-up visits significantly impact patient outcomes. Research indicates that patients who had a follow-up visit after discharge were twice as likely to prevent readmission within 30 days. Another study by McKinsey, employing a machine learning (ML) model, predicted that patients who missed or did not have a primary care follow-up were 23 % more likely to experience a 30-day readmission.
Follow-up appointments with primary care physicians (PCPs) are fundamental to care coordination, strengthening patient adherence to post-discharge instructions regarding medication regimens, dietary guidelines, and activity restrictions. They empower healthcare providers to closely monitor patient progress, enabling swift intervention in case of deterioration or non-compliance, thereby preventing readmissions. Moreover, offering on-call support from a nurse practitioner showcases dedication to patient-centered care, fostering trust and enhancing patient satisfaction.
Active patient engagement is vital to patient-centered care. But, this level of engagement is only achievable when healthcare providers empower their patients with healthcare resources and materials, enabling them to take charge of their well-being.
Access to valid and reliable health information is essential for promoting patients' health literacy. Patient portals enable providers to share medical content, such as educational pamphlets and multimedia health content. Patients can better understand their medical conditions, treatment options, preventive measures, and self-care strategies with this information and make informed decisions about their health. It also encourages them to adopt preventive behaviors and prompts them to seek early interventions, ultimately leading to improved health outcomes.
Positive patient experience relies on care quality in-patient and during ToC. Patient engagement tools are vital for continuous care coordination, especially after a hospital discharge. Healthcare providers must leverage digital technology to effectively communicate with their patients, prevent missed follow-up appointments with constant reminders, and offer round-the-clock support through open communication channels, ensuring seamless care transitions and enhancing the overall patient experience. Furthermore, these tools empower providers to actively involve their patients in their healthcare journey and encourage them to take control of their well-being, ultimately improving patient outcomes.
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