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Extending health-system reach: Why Transitions is vital in the post-COVID-19 era

Painful as it has been, the COVID-19 pandemic has had much to teach healthcare-organization leadership.

Among the most instructive insights to come from the COVID-19 pandemic is this: that although a customer’s discharge from a healthcare facility may be the final task in a care encounter, it is far from the end of an organization’s concerns. In a coronavirus case, as in so many other cases, so much depends on what happens after a customer leaves a facility.

How well they understand their medication instructions, how vigilantly they watch for signs of deterioration, how much (or how little) support they receive from their loved ones—none of these factors are within organizations’ direct control. But they can have a tremendous impact on outcomes.

All this makes a strong case for an expanded role for healthcare organizations. Their care must reach beyond the four walls of their facilities, to ensure patients stay safe and healthy long after their incidents of care.

For this, there’s no more useful tool than NRC Health’s Transitions solution.

Here are four ways that Transitions meets the needs of the moment—and prepares healthcare organizations for an uncertain future.

Preventing readmissions

First and foremost, Transitions leads to better clinical outcomes for patients.

The platform uses interactive voice recognition (IVR) technology to reach 100% of customers within one day of their care encounter. From there, it surveys patients to ensure that they understand post-discharge care instructions, and to check for any emergent symptoms. Patients can be directed to relevant care staff if they have any lingering questions, and staff, in turn, are automatically alerted if patients show any concerning signs of deterioration.

The aggregate effect of these interventions is profound. Resolving simple questions over the phone can ease patient anxiety and pre-empt the need to see a second provider. On the other hand, if something more serious has arisen, a phone call might mean the difference between a follow-up appointment and an urgent visit to the ED. During a situation like the COVID-19 crisis, amid all the evolving and contradictory information a patient may be exposed to, answering a simple question in a straightforward manner may even save a patient’s life.

Via Christi Health, the largest healthcare service provider in Kansas, noted these benefits when it deployed Transitions across the organization. Thanks to Transitions’ automated follow-up calls, avoidable readmissions were reduced by 90%.

To put an even finer point on it, Via Christi leadership conducted a comparative study. They found that patients who discharged without a Transitions call saw a 9% readmission rate, versus only 4% with one.

Reducing the administrative burden

As an idea, post-discharge calls are nothing new. For many healthcare organizations, in fact, reaching every patient after their care episodes remains an operational aspiration.

“As a result of Transitions, our patients get healthier, Via Christi’s readmissions rates have declined, and we have been able to reduce unnecessary utilization of the most expensive settings of healthcare.”

—Robyn Chadwick, LSCSW, Director of Operations, Via Christi

However, high volumes can be a barrier to making this aspiration a reality. When daily discharges run into the hundreds, it can be nearly impossible to reach everyone. It takes a small army, and an untold number of hours, to make that number of calls. Existing staff don’t have the hours to spare (especially under the strains of a pandemic), and hiring on more can be prohibitively expensive.

That’s why Transitions fits so nicely into a post-discharge-call workflow.

Since the vast majority of patients need very little post-discharge assistance, an automated approach is a sensible, cost-effective way to reach them. Transitions takes a first pass at the entire patient population, calling attention only to those patients who actually need human assistance.

At Nebraska Medicine, for instance, Transitions reduced the number of necessary post-discharge calls by over 74% while achieving 100% coverage for its patients.

Such a stark reduction in administrative burden is quickly reflected in the bottom line. At Houston Methodist, costs for the organization’s

“Where Transitions is really valuable to me is in its data. We don’t have to guess anymore at problems. We can identify them with quantifiable precision.”

—Karen E. Doyle, SVP of Nursing and Operations, University of Maryland Medical System

post-discharge-call program quickly plummeted after the implementation of Transitions, from an estimated $12 million to just $2.5 million. Simply put, Transitions took a very cumbersome process, and made it easier.

Increasing satisfaction

A final benefit of Transitions, though it’s not always reflected on balance sheets, is nonetheless extremely important: it improves the healthcare customer experience. There are two vectors for this improvement.

First, Transitions serves as a vital source of feedback data.

Through its automated outreach, organizations are able to quickly assess the clarity of their post-discharge instructions. From there, they can improve communication protocols if necessary, or coach specific providers on how to reach patients better. The importance of this clarity, especially in the midst of a healthcare crisis, cannot be overstated.

Second, the Transitions call itself leaves patients feeling happier with their care episodes.

Receiving a post-discharge call can have a powerful emotional impact on patients. It reinforces a sense of connection with providers, and shows patients that they’re still being cared for. Transitions, in effect, is one more way to lend a patient a voice—something that every healthcare customer appreciates.

This was borne out in quantitative results at the University of Maryland Medical System (UMS). There, the deployment of Transitions quickly led to a marked increase in HCAHPS scores: an 11% increase in “Hospital staff took my preferences into account” and a 5.6% increase in overall composite scores.

Extending care where it matters

More and more, organizations are reaching the consensus that care doesn’t stop when a customer leaves the building. Leaders are broadening their visions and expanding their reach into their communities to better care for those they serve. It’s a laudable effort, and one that, during this global pandemic, couldn’t be more urgent—and it’s a step that Transitions can help empower.

“When you’re calling every patient, you face a situation where only a tiny minority—one in 10 patients—actually needs follow-up. You don’t want to miss them, but you don’t want to squander all that time. With Transitions, we can catch the patients who need help, without taking staff away from their work.”

—Jeremy Carr, Lead Advisor, Patient Experience, Nebraska Medicine

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