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Best practices for safeguarding patient care transitions during COVID-19


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As we prepare for the apex of COVID-19 in the United States, hospitals continue to express their growing concern over the lack of beds, clinicians and personal protective equipment (PPE). A Kaiser Health News article brought to light the issue that some patients are caught in “no man’s land” as providers look to free up beds for incoming patients while nursing homes look to safeguard current residents and staff by putting a hold on referrals.

Current processes to safeguard patient discharge and care transitions are being pushed to keep up with the speed needed to support the sheer numbers of patients projected to be impacted by COVID-19. As health plans, providers and post-acute care centers work diligently to drive collaboration while safeguarding the well-being of patients, there are a few best practices that are worth prioritizing:

Understand the Full Patient Landscape –Before a hospital or health system discharges a COVID-19 patient, they need to carefully assess and coordinate the patient’s transition while dealing with the need to safely expedite these care transitions given the potential for vast increases in new patients arriving in need of critical support.

In order to appropriately care for these patients, providers – and health plans for that matter – need insight on what is happening to their patient populations across the care continuum. Patient-level data analytics – including where patients are being treated for COVID-19 – can offer health plans, providers and post-acute care centers a more comprehensive picture of the patient landscape so more intelligent patient care, coordination and discharge can rapidly be offered during this time of need.

Identify Patients that can Thrive at Home
To increase capacity for COVID-19 patients, acute and post-acute providers can identify which patients can be discharged and to where they are best suited to be transitioned for optimal outcomes.

The reality is that most non-critical patients have the ability to recover best in the comfort and safety of their own home. To be discharged home, however, providers need to feel confident that a patient will be able to thrive on his or her own.

Developing a series of questions that are based on years of patient outcomes data – such as whether the patient has stairs and if they can open jars on their own – allows providers to fully assess whether a particular patient is suited for discharge to home. Intelligently identifying patients who can thrive at home will allow acute and post-acute providers to open up space for more critical patients on a faster timeline.

Streamline Communications
The value of intelligent, swift communications across the board during a pandemic cannot be overrated. This is particularly true when streamlining communications for the discharge of patients from acute care settings to intake at post-acute care settings. When it comes to identifying the next appropriate, safe, quality care placement for a patient, time is of the essence and can make the difference between life and death in some cases.

In order to better track patients through the continuum of care, many facilities have begun to identify patients with one of three diagnoses – confirmed COVID-19, suspected COVID-19, or no COVID-19. In addition, many of these organizations are utilizing care coordination technology which seamlessly helps case managers more quickly identify, communicate, coordinate, and place patients in the best fit, high quality care facility.

Utilize Non-Clinical Approaches
One of the best ways to confidently send a patient home is to provide at-risk populations and seniors with access to non-clinical, home-based care support. For example, a team of non-clinical leads making calls to patients in their homes to see if they need help coordinating services that will deliver groceries and medications. These types of community outreach and support services help ensure that those most likely to be impacted by COVID-19 have the support they need to stay at-home and reduce their potential exposure.  

Together, these best practices will help reduce exposure to COVID-19 for at-risk populations, accelerate care transitions by ensuring patients are placed in the most clinically appropriate place, for the highest quality care and for the right amount of time – while also driving a simpler and more collaborative provider experience.

About the author: Jay LaBine, MD is the Chief Medical Officer for naviHealth.


Visit naviHealth's dedicated COVID-19 resource page