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Repisodic Blog

Sharing insights, impact and successes in our mission to help health systems discharge every patient.

Using Data to Improve Care Transitions


Transitioning from an analog to a digital workflow can unlock data that improves care transitions.

A lot happens in the patient journey at the point of hospital discharge. For many patients, that includes setting up post-acute care either in a home setting or in a healthcare facility. Setting up these services has always been logistically challenging for hospitals, primarily because so many of the processes are manual: conducted via phone calls, texts, faxes, web searches, and even through paper brochures and directories. On top of this, case managers must coordinate the various stakeholders involved in the patient’s care, from family members to insurance companies to durable medical equipment providers and more. It’s a complicated process where almost all of the work happens manually and ad-hoc outside of the hospital electronic health record system (EHR).

Bringing Technology into the Care Transition Workflow

As the role of case management becomes increasingly important in value-based care payment models, hospitals are using digital health tools to address inefficiencies in the care transition workflow. Aside from the obvious benefits of reducing manual tasks, moving to a technology-enabled process generates incredible amounts of data that care management and other hospital executives can use to better understand what is happening when patients are being discharged from the hospital.

Data Driven Care Transitions

Health systems can use data to analyze what happens during patient care transitions and find areas for improvement. For example, just knowing the most common insurance plans and clinical service needs those patients have at discharge can dramatically inform the effectiveness of the partner post-acute care networks and collaboratives. Understanding which options are presented to patients at discharge together with where and how long patients take to make decisions can reveal inefficiencies in workflows. Availability data, such as having insight into which post-acute care providers are most often accepting or denying patient referrals, is incredibly powerful for the evaluation of partner networks and speeding up care transition.

Using data insights to address these inefficiencies can reduce hospital length of stay, increase use of high quality and partner/network post-acute care providers in the community, and ultimately improve the patient experience and post-hospital care journey.

To learn how Repisodic is using data to help leading health systems improve care transitions, click here.