Seven key drivers of patient transitions

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Neil Gulsvig
Neil Gulsvig

What strategies should a provider adopt in order to be on the “A” list as a preferred provider of short-stay and transitional care services in today's ever-changing and challenging marketplace? And are you on the “A” list of preferred providers in your community? With the emergence of bundled payments, ACOs, hospital readmission penalties, and other external factors, the market today is demanding more from providers than ever before. More and more emphasis is being placed on the short-stay patient and their successful transition through the care process.

In order to truly succeed at managing this critical part of any post-acute, short stay care plan, providers must not only manage their patient transitions well, but they must engage their patients early on in the admission process, while at the same time, preparing the patient to manage their health condition post transition. This is no longer a nice-to-have concept; In order to stay competitive, relevant and favorable to hospitals and payers, short-stay post-acute providers must make a renewed commitment to their patient transition strategies.

Does your organization know what the critical components of a successful patient transition are? Align has identified seven key drivers:

  • Driver #1: Early and active patient engagement. Patients who are actively engaged throughout a post-acute stay are more likely to be successful managing health care needs when living in the community.
  • Driver #2: Identification of expectation gaps. Post-transition failures can be related to unrealistic patient and family expectations that were not adequately addressed during the stay.
  • Driver #3: In the Moment patient feedback. Measuring the patient's experience while they are with you, when you still have time do to something about concerns is critical. You cannot manage their perceptions and experiences after they have left your care.
  • Driver #4: Timely, relevant patient education. Timely and relevant patient education is often totally lacking, or in many cases, poorly done. This can leave the patient with knowledge deficits that impact the ability to self-manage.
  • Driver #5: Patient readiness to self-manage. Confident patients and families at the time of transition are much more likely to successfully self-manage outside of your care. How do you know whether your patients are prepared to transition to a lesser level of care?
  • Driver #6: Clear post-transition instructions. It is not uncommon for patient transition instructions to be poorly written, unclear, hard to understand and hastily pulled together at the last minute. Lack of clarity has the potential to lead the patient right back into the healthcare system when simple and clear instructions may have prevented that.
  • Driver #7: Post-transition follow-up. Discharge no longer means “good-bye and good luck.” “A” list providers will be those who recognize that the emerging face of healthcare demands successful transitions and positive post-discharge outcomes. You're going to need to know how your patients did after their transition from your care.

How can a provider manage each of these drivers to create successful patient transitions? In our upcoming blog series, “7 Key Drivers of Successful Transition Planning,” we will look at each driver in depth and offer insight and questions to help you evaluate your transition planning process. Successful transitions lead to engaged patients. And we know engaged patients will have a better experience overall during their stay with you and be better prepared for successful post-transition outcomes when the key contributors to success are well-managed during their stay. 

Neil Gulsvig, CEO of Align, has more than 35 years of experience in the field of senior healthcare and extensive knowledge in human resources, communications and operations. Align is focused on developing integrated solutions that help providers reimagine patient experiences through engagement and successful transition planning.  

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