A key element of discharge planning - the selection of the next site of care - is more important and more complex than ever before, due in large part to the advent of the BPCI program and the episodic approach to care. Once the realm of laminated checklists, frayed brochures and quick conversations, hospitals are now finding technology to be a powerful tool to assist them in the selection of an appropriate next site of care.
One of the tenets of the BPCI program is to put the patient’s needs at the center, and selecting the appropriate next site of care is essential to a successful BPCI program. While many patients will need round-the-clock skilled nursing care to recover, not only is this not the case for all patients, but too much care can be just a detrimental as too little care.
The New York Times recently shared that of the 1.4 million Americans in nursing homes, some 155,000 do not need the skilled nursing care such facilities provide. The individuals interviewed for the article, not unexpectedly, reported depression and low quality of life due to these circumstances.
Patients discharged to SNFs vs. those who recover at home may be twice as likely to fall compared to those who recover at home. According to a paper published in the Journal of the American Geriatrics Society, up to 60% of nursing home residents fall each year. For community-dwelling elderly persons that number is on average 33%.
Lyndsey Lord, RN, BSN, MBA explains, “think of getting up at night in a hotel room. You have to fumble to find your way. Now think of an elderly individual who has gone from one unfamiliar location to another. The potential for missteps and falls is compounded.”
The option to recover at home has become increasingly viable, as home health agencies expand and are able to provide the services Medicare defines as skilled needs. Research indicates that patients who are appropriately discharged to home with home care fare as well as, if not better than, those discharged to SNFs and experience equivalent readmission and mortality rates.
Not only is the right care at the right time paramount for patients, the selection of the next site of care can be the biggest swing lever in the success of a BPCI program. The Genworth 2015 Cost of Care Survey says the national median day rate for SNF care is $250. Compared to $160 per day for home care, the impact on cost of care is significant. Providers must also consider the risk of rehospitalization and the impact on patient wellbeing, as well as the cost of readmission penalties.
With all these factors to balance, technology can enhance the clinician's ability to select the best post acute plan for the patient. A discussion of electronic tools in Nursing Times advocates the use of computerized decision support because of the ability
to match patient information with a set of algorithms to produce a patient specific assessment.
Remedy has developed a unique decision support tool for case managers, physicians and all care team members to use to help determine the best post acute plan. The CARL (Care At the Right Location) tool was created through the collaboration of a team of clinicians, data analysts and software developers. It is designed to support case managers and physicians when discharging patients from hospitals.
The keyword is support. In what Remedy’s Chief Medical Officer Win Whitcomb, MD, MPH has dubbed the crucial conversation, the recommendation about the next site of care provided by a decision support tool is at the core of conversation with the clinical care team, the patient, family and caregivers. This recommendation can allow clinicians to explore a range of options and have a more sophisticated conversation.
Sometimes patients or caregivers assume that a nursing home stay is the only option after discharge. Or for some clinicians, discharge to a SNF is the default. It is notable that a study of the CARL Tool’s use showed that the tool recommended 26% fewer discharges to post acute care facilities, 19% more discharge to home and 11% more discharges to home with Home Health Agency. In the past when SNF or PAC care was not required, there was little incentive and even less support for case managers and physicians to suggest alternatives. Supported by the recommendation of the CARL Tool, clinicians can have the crucial conversation that determines the most appropriate next site of care - one that offers care at the right level for the individual.
How does the CARL tool work?
The CARL tool pulls critical information from the patient’s medical record – ability to ambulate, cognition, and ability to perform activities of daily living; availability of a capable caregiver; post acute physical, occupational, and speech therapy needs; and post acute skilled nursing needs. This data is scored and that number is the basis of a recommended post acute site of care, with the low end of the range indicating Home without Part A Home Health Agency services (HOM), the middle portion of the range indicating Home with Part A Home Health Agency services (HHA), the high end of the range indicating Post Acute Care Facility (PAC).
There’s an important place for decision support technology in a BPCI strategy because of the increasing importance of the selection of the next site of care and the need for standardized discharge planning. Decision support tools, such as the CARL tool, can help patients have higher quality recovery experiences, as it can identify when discharging outside of a SNF or care facility is appropriate.