HJBR Mar/Apr 2024

HEALTHCARE JOURNAL OF BATON ROUGE  I  MAR / APR 2024 35 Dana Lawson, DNP, MHA, MSN, APRN, CCM Senior Vice President of Population Health Clinical Operations and Health Equity Louisiana Healthcare Connections social workers, case managers, di- eticians, pharmacists, behavioral health therapists) in developing in- novative interventions that produce positive outcomes and ensure safe discharge is the primary goal but the most challenging to achieve. While a multidisciplinary approach may be time-consuming and labor-intensive, the benefits of incorporating mul- tifaceted expertise for high-needs, high-cost patients are well worth the investment. In addition, it curbs un- necessary spending and disruption. 2 • Optimizing patient and caregiver engagement: Central to the success of any discharge plan is assessing how engaged patients and caregivers are. These evaluations must be delib- erate and consistent to identify what outcomes of care are most important, to assess needs and strengths, to fa- cilitate respectful collaboration, and to promote shared accountability and decision-making during care plan- ning and follow-up. And finally, what’s in it for me? The obvious benefits to patients, fam- ilies, and communities notwithstanding, here is what hospitals and healthcare sys- tems stand to gain from implementing ef- fective care transition programs: • Reduced hospital readmissions: Hospital readmissions not only post financial burdens on health systems, but they also indicate serious gaps in care quality and patient management. According to the Agency for Health- care Research and Quality (AHRQ), the average 30-day, all-cause read- mission rate from 2016 to 2020 was 13.9% with the cost of these readmis- sions 12.4% higher than that of index admissions ($16,300 vs. $14,500). 3 • Decreased length of stay: Patients that remain hospitalized beyond the normal course of a proposed stay are at increased risk for hospital-ac- quired complications, increased costs, and for a negative experience. This represents lost revenue, com- pounding additional financial loss, from patients waiting to transition to the next appropriate care setting. 4 • Improved patient experience and satisfaction: Smooth care transitions contribute to more positive patient experience by fostering confidence, trust, and engagement throughout the healthcare journey. Patients who feel supported during transitions are more likely to adhere to treatment plans, actively participate in self-care activities, and report higher levels of satisfaction with their providers and healthcare institutions. • Minimized risk for regulatory non-compliance: CMS requires hospitals to implement a robust dis- charge planning process, and without one, facilities are subject to violations that may carry significant penalties. Other impacts include poor star rat- ings, risk of failed accreditation, in- eligibility for value-based programs, loss of contracting relationships, neg- ative feedback on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and the list goes on. Care transitions serve as a linchpin in the modern healthcare landscape and, when successful, facilitate a seamless pro- gression between levels, settings, and pro- viders; optimize delivery systemefficiency; and enhance overall health outcomes. De- veloping, maintaining, refining, measuring, evaluating, and investing in care transi- tion programs take time, labor, resources, support, intentionality, consistency, and collaboration between the organization’s top brass and its frontline staff. Everyone must own some aspect of moving patients seamlessly across the care continuum without risk of adverse events. Recogniz- ing the importance of, and prioritizing, comprehensive care transitions assures integrated care that is patient-centered and that improves clinical outcomes, en- hances the patient experience, and drives sustainable care delivery models. n REFERENCES 1 Centers for Medicare and Medicaid Ser- vices. “Transition of Care Summary.” Last updated May 2014. https://www.cms.gov/ regulations-and-guidance/legislation/ehrincen- tiveprograms/downloads/8_transition_of_care_ summary.pdf 2 Davidson, G.; Austin, E.; Thornblade, L.; et al. “Im- proving transitions of care across the spectrum of healthcare delivery: A multidisciplinary ap- proach to understanding variability in outcomes across hospitals and skilled nursing facilities.” American Journal of Surgery 213, no. 5 (April 5, 2017): 910-914. doi: 10.1016/j.amjsurg.2017.04.002 3 Jiang, H.J.; Hensche, M.K. “Characteristics of 30-Day All-Cause Hospital Readmissions, 2016- 2020.” Agency for Healthcare Research and Qual- ity. Agency for Healthcare Research and Quality, Sept. 22, 2023. www.hcup-us.ahrq.gov/reports/ statbriefs/sb304-readmissions-2016-2020.pdf 4 American Hospital Association. “Issue Brief: Pa- tients and Providers Faced with Increasing Delays in Timely Discharges.” December 2022. https:// www.aha.org/system/files/media/file/2022/12/ Issue-Brief-Patients-and-Providers-Faced-with- Increasing-Delays-in-Timely-Discharges.pdf Adistinguished healthcare leader with a career span- ning over two decades, Dana Lawson, DNP, MHA, MSN,APRN,CCM, is responsible for overseeing a di- verse array of programs, including casemanagement, community innovations, health equity, utilization management and review,chronic caremanagement, specialized behavioral health, strategic initiatives, and clinical operations. She is dedicated to forging innovative partnerships with healthcare providers and community organizations aimed at enhancing the health, quality of life, and accessibility to care for individuals,families,and communities.With a wealth of experience, Lawson is known for her innovative leadership and clinical expertise in acute care,home health,primary care,and advanced nursing practice.