Using Cutting-Edge Tools to Support the Health Coach in Post-Discharge Point of Care

By Marlene Grasser

Key to an effective healthcare experience is caring for patients during the entire continuum, including the transition out of the acute hospital setting into their own homes. Dr. Harlan Krumholz, a Harvard professor of Medicine and Investigative Medicine and Public Health, calls this transition the “post-hospital syndrome,” during which patients are in a period of “generalized risk.” It is precisely this portion of the continuum of care where healthcare call centers can demonstrate their human and technological value.

For decades healthcare call centers have been the source of reliable information for day and night calls, ranging from concerned parents who need help with a sick child to injured “weekend warriors.” Nurses answer questions and provide guidance utilizing software that includes evidence-based triage guidelines and health information, with the ability to document the call encounter. The call center also provides specialists with referrals, utilizing a fair and equitable rotation, and helps attract and build physician relationships with the hospital. This technology also provides the ability to electronically notify a health coach within the call center that a discharge from the hospital is planned and action is required to ensure the safety of the patient affected.

Timing, follow-up, education, and access are critical for success in a post-discharge program. The ideal software application provides the structure and tools needed to address each of these fundamental pieces. It’s essential to be able to interface with the hospital’s information system and use applicable triggers to load patients into the health coach’s queue for follow-up in person or by phone. Initial assessment within hours by the coach can reveal stressors and potential dangers beyond the acute illness, which, if unaddressed, could lead to a worsening health condition, re-admission, or even death.

After assessment and identification of risk factors, medication reconciliation (comparing drugs previously taken at home versus new prescriptions from the hospital event) must be performed to assure that the proper medications are obtained and taken as ordered. Medication adherence as a follow-up to reconciliation ensures that any issues – such as side effects, cost, or access to prescriptions – are addressed. The health coach needs a system to track these activities to help prevent unnecessary complications that can occur from medication mistakes.

Through a post-discharge solution, health coaches contact the patient’s primary care provider (PCP) to either confirm or schedule a follow-up appointment. The health coach can assist the patient in preparing for the appointment by listing questions or concerns. Then, an automatic reminder call that has been set up in the software, along with a text of directions or a map to the PCP’s office, provides additional support to help the patient keep the appointment. Any difficulties with transportation can be handled with a service referral.

When additional education and support is needed for specific disease states such as heart failure or diabetes, extensive care plan blueprints need to be available to help guide health coaches. This is especially important when the care extends beyond thirty days post discharge. Scheduled follow-up calls with high-risk patients every two to four weeks can help prevent an exacerbation of health issues and a subsequent re-admission.

Extensive assessment and management tools are needed to support and document the health coach’s activities with each patient and provide a road map from which constant process improvement can occur. Outcome- and trend-reporting provides a review of clinical indicators of individual (as well as aggregate) mental and physical well-being to determine the success of certain interventions and highlight the need for others.

Recognizing that healthcare call centers are crucial to addressing this high-risk period on the healthcare continuum is just the beginning. Ongoing advances in today’s technology provide the ability for the call center to support multifaceted care. From triage to referral, and from post-discharge follow-up to care- and case-management, reporting on successes and challenges insure that patients are cared for well beyond their hospital stay.

Marlene Grasser, RN-C, BSN, is the western region vice president of sales for LVM Systems. For more information about LVM Systems’ re-admission management solutions, please call 480-633-8200 x620.

[From the April/May 2014 issue of AnswerStat magazine]