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Improving referrals to post-acute care
Educating clinicians is first step
After years of research regarding post-acute care referrals and outcomes of at-risk patients, a researcher has concluded that more education and discharge planning resources are needed.
"We need to do some work in acute care settings, educating clinicians about what home care can do for patients," says Kathryn Bowles, PhD, RN, FAAN, an associate professor at NewCourtland Center for Health and Transitions at the University of Pennsylvania School of Nursing in Philadelphia. Bowles has published numerous studies about discharge planning and post-acute care referrals.
Here are Bowles' tips for improving discharges to post-acute care services:
Educate clinicians about home health benefits.
"If we give them a better understanding of the value of home care nursing, then clinicians will do a better job of realizing the patient might benefit from home care nursing," Bowles says.
For example, heart failure patients who often return to the hospital with acute flare-ups of symptoms could benefit from having a home health nurse visit them after discharge, Bowles notes.
"The home care nurse could teach them how to watch their weight, evaluate their diet, etc.," she says.
Take time to communicate all pertinent patient information to the home health nurse.
It also would help improve outcomes when these patients are referred to home health care if discharge planners would let the home health nurse know how frequently the patient has been rehospitalized and of any other priority issues, Bowles adds.
"Hospital communication should be improving, but we still have a gap of getting that information from the hospital to the home care setting," Bowles says.
For instance, in Bowles latest study she assessed the disease management approach of four home care agencies by examining the care provided to patients newly admitted to home care.
"I asked nurses to document patients' hemoglobin A1C, and the home care nurses knew the A1C of their diabetic patients only 13% of the time," Bowles says. "They were not given that information by the hospital."
* Note national data and trends.
"There's work going on nationally with the Continuity of Care record, and we should be paying attention to the contents of that," Bowles says. "Discharge planning departments should make sure they have access to those data elements within their electronic system, and they can produce summary documents that can be transmitted or faxed to home care agencies."
Likewise, home care agencies need to collaborate with acute care discharge planners to say, "This is the kind of information we want," Bowles notes.
"I don't see that collaboration going on between discharge planners and home care," she adds.
"Discharge planners need to ask themselves whether their system provides this information, and how can we get it to the home care agency," Bowles says.
* Use electronic records to make time more efficient.
"Discharge planners are overwhelmed," Bowles says. "People are just getting sicker and sicker, and over the years, their cases have become more intensely complicated."
Discharge planning is an overwhelming job, she adds.
"So we need to use the electronic record to help us and to transfer information," Bowles says.
"My work is about developing decision-support tools for referral decision making, so we can help clinicians identify people, augmenting their decision-making process, who might need a referral," Bowles says.
The tools could send an electronic alert to clinicians, saying, "Have you considered a referral for this patient because their characteristics suggest they might benefit from home care services," Bowles adds.
Electronic records and tools might be a good way of overcoming time constraints in the discharge planning industry, Bowles says.
For more information, contact:
Kathryn Bowles, PhD, RN, FAAN, Associate Professor, School of Nursing, University of Pennsylvania, 418 Curie Blvd., Philadelphia, PA 19104-4217. Telephone: (215) 898-0323. Email: firstname.lastname@example.org.