The digital healthcare vendor, Lumeon, has announced the launch of a Care Transitions Management solution, which supports a more co-ordinated approach to discharging patients. The solution is enabled by the latest release of Lumeon’s Care Pathway Management (CPM) automation platform, which is deployed in more than 70 health systems across the US and Europe.
Readmissions have a huge impact on the cost of providing healthcare, as well on the patient experience and patient outcomes.
In 2018 (the last year for which figures are currently available), 70 NHS hospital trusts (out of a total of 125) provided watchdog Healthwatch, with a breakdown of their emergency readmission figures. This revealed that there were 484,609 emergency readmissions within 30 days of discharge in 2017-2018 compared to 397,952 in 2013-14 – a rise of almost 22%. Readmissions within 48 hours rose by a staggering 30.5% from 82,674 in 2013-14 to 107,960 in 2017-18. According to a report by the Nuffield Trust and Health Foundation think tanks there were 1.38 million readmissions (both emergency and longer term) in 2016-17. All of this at an average cost of £222 per bed per day, with specialist beds costing considerably more.
It’s important for both the efficient running of the NHS, as well as the patient’s wellbeing, that they are not staying in hospital longer than needed. Poor discharge experiences also result in significant anxiety for patients – leaving people uncertain about their diagnosis and support (Vetter 2003, Kydd 2008, Ellins 2012). In order to ensure that patients are not being readmitted days after discharge though, it’s vital that all healthcare agencies work together.
Reducing readmissions is, however, challenging because of all the variables in play. Independent reviews (see, for example, Kripalani, Jackson, Schnipper, Coleman 2007) have highlighted a range of challenges in providing high‐quality care during hospital discharge and the subsequent period of transition, including inpatient/outpatient discontinuity (eg poor follow-up in primary care), changes and discrepancies in medication regime, poor execution of self-care responsibilities and social care support, and ineffective physician/patient communication.
The secret to tackling the readmission problem is to identify the patients who are most at risk and focus resources on them, to personalise care plans, and to communicate with clarity while monitoring for compliance.
Lumeon’s Care Transition Management Solution supports more effective communication between primary care and outpatient providers, while helping patients through the critical period following their discharge from hospital. It brings together three capabilities into one platform to enable the coordination of activities and decisions across care journeys; the autonomous management of tasks, communication and interactions; and the unification of the experience throughout the journey. These capabilities are enabled by its Pathway Engine, which delivers more effective:
- Risk evaluation – enabling risk-stratification of patients at discharge, with readmission risk scoring, decision support and automated assignment to a personalised care transition pathway
- Appointment coordination – a prompt check-in with patients via SMS to make sure follow-up appointments are booked, and timely reminders to optimize attendance
- PCP notifications – automated transfer of key information to primary care or alternative post-acute providers, including scheduling priorities, pending test results and alerts when patients are admitted/discharged
- Discharge instructions – automated distribution of personalised care instructions based on information captured at discharge
- Patient monitoring – automated co-ordination of key activities to monitor patient recovery, using a combination of digital, telephone and in-person interactions, according to the need of each patient.
“The issue of preventing patient readmissions continues to be a huge thorn in the side for health systems,” said Robbie Hughes, Lumeon’s CEO. “Existing solutions have only skimmed the surface and exacerbated the problem by causing fragmentation in care. Lumeon brings a unique approach that quickly addresses health systems’ deepest concerns by first working closely with them to analyse and design relevant pathway-based approaches, then deploying our automation platform to put the solution into practice, ensuring continuity in care with efficient use of resource.”
This type of technology has been developed for the US market where time is money and where patients will sue if you get it wrong. But it’s just as applicable for socialised medicine systems, such as the NHS, where aging populations are stretching available resources. It’s actually a great example of how technology can deliver a virtuous circle of improvement.
As important as operational efficiency is to husband precious resources, this solution is just as much about improving patient outcomes. But the third, and often overlooked, benefit it delivers is to health service employees (doctors, nurses, technicians and professionals) who often become frustrated and disenchanted with unwieldy and inefficient processes that waste their time and mean their patients are not getting optimal care. Helping them do a better job and reducing their administrative burden makes for a happier, more productive workforce, which inevitably leads to happier patients and lower staff turnover.
This latter factor is critical for the NHS, which is experiencing a staffing crisis. NHS England, for example, has 40,000 nursing and midwifery posts that are unfilled, with London alone having 10,000 unfilled nursing posts. Using technology to support the administrative burden frees staff up to perform what they like doing best – patient care – boosting morale and making the best use of their skills.