Connecting the Divide Between Inpatient and Outpatient Care
Healthcare executives predict a major shift in admissions from inpatient to outpatient settings, according to Premier Healthcare Alliance’s spring 2013 Economic Outlook. More than two out of three survey participants expect outpatient volume to rise in 2013, while one in four predict a drop in inpatient volume.
While healthcare organizations must connect episodes of care, closing the gap between inpatient and outpatient care may be even more pressing. Only then will healthcare develop integrated networks that include hospitals, health systems, ambulatory care centers, community clinics, long-term care facilities, home care agencies and medical groups, that can work together to coordinate care and share accountability for quality, cost and outcomes.
Critical Drivers in Clinical Integration
The Accountable Care Act (ACA) encouraged the formation of medical homes and accountable care organizations (ACOs) to achieve the Triple Aim promoted through the Institute for Healthcare Improvement (IHI). In doing so, healthcare providers have the potential to improve the patient experience and the health of populations, while lowering per capita costs. The ACA is helping to facilitate the transition from episodic, fee-for-service payment to more coordinated, high-quality, low-cost, value-based care delivery across the care continuum.
Accountable care demands the reform of healthcare delivery. The key to successful clinical integration is to build high-performance organizations of physicians, specialists, hospitals and others that are willing to adopt and use information technology and innovative care systems to prevent illness, enhance safety and quality and coordinate and integrate care. In the process, these organizations become accountable for the quality and cost of care delivered to a defined patient population.
Equally relevant to closing the inpatient/outpatient divide are the escalating requirements of meaningful use. While Stage 1 required healthcare providers, including hospitals and health systems, to demonstrate an attempt to achieve meaningful information exchange. Proposed requirements for Stage 3 set the bar higher by zeroing in on care coordination, longitudinal care planning and information sharing across the care continuum.
Also playing a role in inpatient/outpatient integration is the push toward clinical integration, which demands information systems designed to provide clinicians with access to meaningful, actionable information at the point of care decision making. Among the requirements are data aggregation and exchange platforms, redesigned workflow tools, patient and provider portals, population management and performance improvement dashboards and analytics.
Even the Institute of Medicine has weighed in, recommending that provider organizations and clinicians should: “improve coordination and communication within and across organizations” and “ensure safe seamless care” by developing “coordination and transition processes, data sharing capabilities and communication tools.”
The great challenge to achieving new ways of thinking and practicing in the midst of the shifting landscape remains in the how to best create integrated healthcare systems. While an interoperable technology platform is unquestionably needed, so is an interoperable practice platform to expedite the seamless transition of care between inpatient and outpatient. There have been great lessons from a large healthcare consortium that has been studying the critical reality that to automate is not the same as intentionally transforming work cultures and systems to achieve the desired outcomes. Nearly 400 healthcare settings (rural, community and academic) have leveraged the Elsevier CPM Framework™ and Models to achieve the fundamental elements required for best places to give and receive care across the continuum of care. In developing a common practice framework that can be embedded in any technology platform, the following components have been validated as essential for high-quality seamless care:
Shared purpose and values
Polarity thinking skills
Competency in full scope of practice
Integrated competency to halt duplication of services
Partnerships to support networking across the continuum
Evidence-based tools to develop individualized, interdisciplinary, integrated plans of care
Integrated documentation that reflects the patient’s story, plan, progress and outcomes across the continuum
Exchange processes and handoffs that ensure safe, quality care
If providers hope to close the gap between inpatient and outpatient care, they should adopt such an infrastructure that supports continuity of care. Among the most essential steps are:
Provide teams with interprofessional, evidence-based tools. Care coordination and integration of inpatient/outpatient care depend on an interprofessional plan of care. To that end, HCOs should provide teams with interprofessional evidence-based tools to build individualized care plans for patients. Equally important for HCOs: Embed evidence within the electronic health record (EHR) for quick, easy and convenient access and decision making by team members; distinguish between clinical practice guidelines and policies, procedures and protocols; track adverse events and quality measures related to evidence-based content and documentation; and monitor if and how team members use evidence-based tools. Doing so will helps to ensure consistency and continuity between inpatient and outpatient care.
Implement integrated clinical documentation.
Interprofessional care teams committed to coordinated, collaborative care seek integrated documentation systems that capture a patient’s story, needs, problems, plan, interventions and progress while also providing Clinical Decision Support (CDS) tools such as clinical practice guidelines and evidence-based screens, scales and content. The ideal integrated documentation solution is intentionally designed to integrate clinical documentation with care planning using evidence-based guidelines. Diverse clinicians – from nurses and dietitians, to physical, respiratory and occupational therapists – are able to rely on clinical guidelines to guide care that is evidence-based, standardized and that customize documentation to reflect all interprofessional services rendered.
Engage patients and family members. Developed by the National e-Health Collaborative (NEHC) the Patient Engagement Framework calls on providers to move from a provider-centered model to an authentic patient-centered approach by adhering to the steps of inform me, engage me, empower me, partner with me, and support my community.
While healthcare organizations (HCOs) will likely follow NEHC recommendations to invest in information, way-finding, e-tools, forms, patient education and patient information access and generation, they should also consider implementing five core principles of dialogue as learned by the CPM Consortium in their relationships with patients, providers, payers, vendors and government. Whether utilized in face-to-face situations or in digital environments, a disciplined approach to intention, listening, advocacy, inquiry and silence goes a long way to involve and engage patients and family members in care decision making.
Insist on Interoperable HIT Systems
Interoperability is still a problem in healthcare, according to Information Week, largely because of inconsistent adoption and use of EHR systems, inherent defects in interoperability and usability, provider reluctance to re-engineer care processes and dissatisfaction with EMR performance leading to a dangerous “rip and replace” mentality. The solution is for providers to insist on systems that meet the criteria of standardization, ease of use, interoperability and enhanced patient access to and control of information. Providers, in turn, must reengineer care processes and deploy standardized content to make the most of the EHR.
Develop Professional Exchange / Handoffs Processes
To prevent lapses in patient safety and ensure full communication among care team members, providers must adopt a standardized professional exchange report/handoff process. Equally important is crafting an education and review process that ensures competency in exchange skills across the care continuum. Using a collaborative approach, providers must utilize exchange report processes and formats that prepare the next provider to take over care accountability, along with programs that track, monitor and evaluate how team members’ use of reports and use of technology improve care quality and safety.
Allow Professionals to Practice to Their Full Scope of Practice
This begins with having clarity on full scope of practice for each clinical discipline and then intentionally designing evidence-based tools and documentation to help them live it every day. It is not uncommon for clinicians who practice side-by-side not to be clear on the full scope of practice of their peers which will be critical in addressing the divide between inpatient and outpatient care. To specifically address the needs for advancing health care in today’s changing landscape as well, the IOM’s Future of Nursing: Leading Change, Advancing Health Report makes strong recommendations that we remove scope of practice barriers including that 1) All nurses and other healthcare providers must assume full scope of practice and 2) Advanced Practice Registered Nurses (APRNs) practice to the full extent of their education and training. Scope of practice laws and payment policies are the two most significant barriers to expanding care delivered by nurse practitioners, according to a 2013 report from the National Institute for Healthcare Reform. Happily, a variety of states have bills that would facilitate the move toward full practice authority, resolving the shortage and misdistribution of primary care physicians and fostering more coordinated, collaborative, team-based interprofessional care.
We can bridge the gap between inpatient and outpatient care if we remain aware of the shifting demands of accountable care, population health management, clinical integration and collaborative, coordinated and consistent care by government, payers, patients and provider partners. Instead of searching for yet another high-tech fix, HCOs should consider implementation of a comprehensive practice platform that blends evidence-based tools with team competency and compassion. Just as important is the investment in content that supports integrated documentation, patient engagement, interoperable systems, professional exchange, advanced practice professionals, and intentionally designed tools to support coordinated, collaborative care.
Michelle R. Troseth, MSN, RN, DPNAP, FAAN, is chief professional practice officer, ELSEVIER.