In my last post, I said that the first R of success in managing the continuum is to “Resolve what you can.” I pointed out that we have tremendous opportunity to be more effective and efficient in managing the Acute Care Continuum, and that it is crucial we do so in this era of shrinking reimbursement and an aging population. If we do not, the organizations we lead are at severe risk.
In this post, we will cover the other two R’s needed to succeed in this regard. The second R is:
Even if we resolve everything possible at every stage of the Acute Care Continuum, there are still cases that we must refer. Using the ED as an example, if the patient needs more diagnostic testing or treatment than the resources for an ED visit affords, the patient must be referred to a level of care that has the resources to render the appropriate services. The first question is where: observation or inpatient? Next, to the care of whom: hospitalist, cardiologist, pulmonologist, gastroenterologist, etc.? All of these questions stem from our initial diagnosis. Making the right decisions on these referrals will result in efficient and effective care. On the other hand, wrong decisions will have the opposite effect.
It does not stop in the ED. When the patient gets to the inpatient floor and has a complication, the nursing staff has to be able to identify it early and involve the hospitalist who needs to order the appropriate testing and/or consults with specialists to address the issue. Then, the specialist and hospitalist need to agree on what should be done before the patient leaves the acute care setting, and what can wait and be done in an outpatient environment post-discharge.
Lastly, when patients are leaving our care we have an obligation to reinforce with them the things they can do to help them succeed. We must do this even if we know that they have heard it before and failed to heed this wisdom. This is because we never know when a patient will be ready to receive what we have to say. Circumstances change and life teaches everyone.
My own mother was an example of this. She smoked one to two packs of cigarettes from her teenage years until she was almost 50 years old. She tried to quit several times, but could not seem to “kick the habit.” Then, her mother had a battle with breast cancer. That flipped the switch for my mom. It took her from the knowledge that she should quit smoking, to the understanding that she must quit smoking. Lessons can build on each other and people who have never "got it" before may be able to get it today, tomorrow, or next month. We never know if and when that day may arrive for the patient in front of us. Do not let cynicism dissuade us from delivering the education and information that, this time, might get through to the patient and set him or her free from the things that are causing pain and suffering. Do not shortcut on discharge instructions, follow up calls, and patient education about the conditions that beset them. Ultimately, that information, if received, is what can cause them to be able to live well.
So, healthcare reform is here and we need to keep people well and out of the hospital. Maybe we will get there in the future. But today, we can improve care and efficiency if we concentrate on the 3 R's of Success in managing across the Acute Care Continuum:
Resolve What You Can
Refer What You Cannot Resolve
Reinforce Right Living
It will require a team effort that cannot tolerate organizational silos, egotistical or turf battling behavior, short-sighted cost cutting by out of touch administrators, or any of the other couple dozen dysfunctions that adversely impact our organizations today. It will take a cultural revolution that truly puts the patients at the center of all our efforts, rather than trying to cycle them through our systems and processes at our convenience.