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The Five Elements of Optimal Care Delivery: Cross-Continuum Care Transformation

When it comes to improving care delivery, hospitals and health systems must ensure that standardized, evidence-based protocols are applied across all settings, from pre- to post-acute. Standard care pathways go beyond improving efficiency: they result in better patient outcomes than interventions applied on an individual basis.

Read on to learn more about cross-continuum care transformation, the third of our five strategic elements for achieving optimal care delivery.

Engage the team to identify the best approach

At both the patient and service line levels, diagnosis-specific protocols that are derived from established medical and scientific knowledge will help ensure the proper level of care.

The best way to design these care pathways is by assembling multidisciplinary cross-departmental teams. For example, an ideal team includes: an administrative lead, a department/service line lead and a clinical lead, as well as stakeholders in care management, finance, quality, information technology, education and communications. When all of the care providers play a role in decision-making, the collaborative team can more effectively determine next steps for care delivery. To enhance efforts, it’s best to include a member of the C-suite or other senior leader in the process as a champion of the transformation effort.

Stay accountable to your new standard of care

Once care pathways are designed and approved by the necessary stakeholders and leaders, the following strategies can help ensure smooth implementation:

  • Establish multidisciplinary care teams (pharmacists, nurses, doctors, case management, tec.) for the delivery of evidence-based care.
  • Make sure physician order sets include all evidence-based care components, to help hardwire new processes into place. Otherwise, there can be a tendency to rely upon experience, which could mean selecting different orders or tests for patients than the standard developed by the team.
  • Enable daily reviews of medical records to ensure patients are receiving all evidence-based care. A robust clinical decision support tool can look across a hospital’s patient population and view the patients whose care was impacted by proper, clinically-based guidelines or if clinically-supported guidelines were overridden in the electronic medical record and why.
  • Use checklists to ensure patients have received all evidence-based care prior to discharge. A discharge checklist serves as a safety net for the care team to verify that patients have received all vital care elements, such as education on how to use a new inhaler, before they leave the premises. This further assists patients in following appropriate care at home and helps prevent unnecessary readmissions.
  • Provide regular feedback to clinicians on their compliance with scientific standards. With the aforementioned checks in place, leaders should feel comfortable reporting back on compliance with new standards, holding their teams accountable and removing barriers if needed.

Use data and analytics to guide decision-making

In order to effectively monitor performance and track improvements in new standards of care delivery, healthcare organizations need to set up a framework for recording and analyzing the data transactions that occur daily. Tracking analytics that incorporate data across the continuum can help leaders understand holistic financial, clinical and operational outcomes. Meanwhile, clinical decision support provides deep analytics that can stimulate a positive culture around behavior change by reinforcing evidence-based guidelines.

The first step in establishing effective tracking analytics is to ensure proper clinical documentation. Not only is this crucial to measuring the effectiveness of new care standards, but accurate clinical documentation and coding are crucial to a number of other functions, including: complying with federal payment programs’ reporting requirements; developing accurate organizational quality profiles; achieving optimal outcomes and quality scores; and maximizing reimbursement across the continuum.

With clear and consistent documentation protocols in place, health systems can move on to measure tracking and reporting. An effective technology platform will seamlessly integrate optimization strategies into day-to-day patient care, while common network performance technologies support quality and federal reimbursement program requirements.

Creating and implementing evidence-based care pathways can significantly improve a variety of functions and outcomes — and to maximize the benefits, health systems must commit to implementing these improvements across the care continuum and throughout the organization.

Stay tuned for our next blog post on care delivery optimization, where we’ll offer insights on patient progression.

Learn more now:

Check out the infographic, Transform Care Delivery.

Read the previous blog in the series, Achieving Effective Clinical Alignment.

Download our Creating a Culture of Optimal Care Delivery white paper for more in-depth information.

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