Post-discharge communication plays a critical role in a patient’s healthcare journey, ensuring they continue to recover effectively after being discharged by their care team. For many hospitals, post-discharge engagement is limited to a nurse phone call, which is manual, difficult to staff, and worst of all, ineffective at reaching patients.
The consequence? Patients are slipping through the cracks. This is not only problematic for health outcomes but can also lead to increases in readmissions, lower HCAHPS scores and financial penalties. The reality is that U.S. hospitals experience an average 15 percent readmission rate, costing Medicare an estimated $26 billion annually. Hospitals performing poorly in the Medicare Hospital Readmission Reduction Program (“HRRP”) can be penalized up to 3% of overall Medicare revenue.
In a recent fireside chat at Artera Heartbeat’24, renowned leaders from Vanderbilt University Medical Center and Houston Methodist provided insights into their distinct approaches to post-discharge communication and the transformative role Artera played in their journey. Hosted by Meg Aranow, Artera Advisor, the fireside chat featured Ashley Trambley, Director, Discharge Care Center at Vanderbilt University Medical Center and Theresa Pinn-Kirkland, Nursing Supervisor, Post-Discharge Care Manager at Houston Methodist.
Getting Started: Unique Approaches to Post-Discharge Communication
While both Vanderbilt and Houston Methodist prioritized implementing post-discharge communication in their respective organizations, they took quite different approaches.
On the one hand, Vanderbilt’s journey began with a decentralized model of discharge phone calls, eventually integrating a gap care clinic to support patients during the vital 30-day post-discharge period. They ultimately started with a pilot of nurses cold calling – and through that, they identified a need for automation as there was no way to scale that and support the entire health system. They wanted to create 24/7, 365 access to a dedicated team for all post-discharge needs.
Their next iteration of the Discharge Care Center is what they’re calling the “Discharge Clinic,” which helps review the network of transitions of care, identify congestion points within patient care and facilitate gap closures, as well as medication and therapy orders within the 30-day window after discharge.
On the other hand, Houston Methodist had something in place initially for post-discharge: robocalls. That being said, the health system was searching for a more robust platform that engaged patients more deeply: “While we had something in place, we were limited on when to reach out to patients, we played a lot of phone tag and it just wasn’t an ideal platform for us to use,” said Pinn-Kirkland. When Houston Methodist moved to Artera, they added 18 units across seven hospitals, which meant more patient outreach.
If You Encourage Patients to Reach Out, Be Prepared to Respond
Through the initial learnings of phone call outreach at Vanderbilt University Medical Center, Trambley and her team felt passionate about improving the patient experience, and making it as seamless as possible for the patient: “If you’re going to call me and take time out of your day to respond to this technology that we put in place, I want to be able to answer your questions and navigate you. Our general motto is: if we don’t know the answer, we’ll find out who does. We’ll take the ownership. As a brand, if you can’t navigate your health system, how am I as a patient supposed to figure it out?” said Trambley.
For Houston Methodist, staying within the confines of corporate hours, Monday through Friday, eight to five has been has been somewhat of a hurdle. Since many patients face issues in the evenings and weekends, it can be difficult to get back to patients in a timely manner – factors that can adversely impact patient outcomes, revisits and readmissions. Pinn-Kirkland believes more coverage or extended hours could help more patients.
Both institutions also tackle the issue of communication overload, with patients sometimes feeling bombarded by messages. Pinn-Kirkland suggests: “Patients feel like ‘I’m getting a lot of stuff bombarded at me, but when I have questions, I feel like nobody is there to be meaningfully helpful.’” Houston Methdoist is working hard to get better at this, routing patients to where they need to go, and even @ mentioning relevant team members in the Artera platform to streamline communications to the right department.
Trambley emphasizes that every message sent to patients must be “value added.” Understanding one’s health system and staying attuned to other communications is essential. She notes, “Unified communications governance, especially as we venture into the clinical space, will be crucial. If the experience isn’t seamless and valuable, I would disengage as a patient.”
Achieving Clinical Excellence Through Post-Discharge Communication
Despite the hurdles, both organizations have seen significant results with their post-discharge programs.
“Anecdotally, we all know that if you do a good job with post-discharge care, if you’re helping patients transition home safely and closing these gaps, you end up with patients who are happier, who have better health outcomes, who don’t return to the hospital for unnecessary readmissions or revisits. But it’s hard to quantify that,” said Pinn-Kirkland.
This is why Houston Methodist participated in a study – featured in the British Medical Journal – called “Investigating Patient Engagement Associations Between A Postdischarge Texting Programme And Patient Experience, Readmission And Revisit Rates Outcomes.” The results were substantial, with the “engaged” cohort (patients who responded with 3 or more messages) reporting higher HCAHPS scores, 20 percent fewer revisit rates and 29 percent fewer overall readmissions.
Overall, it’s clear that investing in post-discharge communication is crucial for creating a seamless patient experience. The insights from Vanderbilt and Houston Methodist strongly emphasize the need for personalized communication to enhance patient satisfaction and engagement in the digital era.
As they look towards the future, both health systems are poised to further refine their communication strategies, acknowledging the evolving nature of healthcare. By marrying cutting-edge technology with empathetic care practices, these two forward-thinking institutions illustrate a future where post-discharge communication is both efficient and personalized, catering to both clinical and personal patient needs.
Want to learn more about how your organization can partner with Artera to improve clinical and post-discharge communication? Check out Artera Care Navigator, our new product that empowers Care Managers and Clinical Teams to bridge the gap between hospital and follow-up care.
