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Why the Pre Admission Process is a Critical Part of Transitional Care

Why Pre Admission Is Critical to Transitional CareEditors note: This article is co-authored by Rebecca Murray, Director of Quality & Risk Management at Spectrum Medical Group, Maine's largest multi-specialty, physician owned and directed professional organization.

Today, there is a tremendous emphasis on improving post discharge patient management to:

  1. Prevent costs and risks associated with  unnecessary re-admissions. 
  2. Ease hospital to home transitions. 
  3. Improve the patient experience.
However, to ensure success, initiatives emerging from HCAHPS and readmission programs should include all stages of the patient care cycle, starting with the pre-admission process.


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Hospital Resource Utilization

Many institutions have developed a “passport” concept – essentially a checklist that indicates a patient is ready to come into the hospital. In some circumstances, pre-admission passports can be filled out by patients on line but are often created through an interview with nurse. They are designed to ensure:

  • All patient requirements have been identified.
  • The patient understands what is going to happen and the associated risks.
  • The patient and hospital resources are scheduled appropriately.

All three points are clearly important from a financial perspective – operating room cancellations don’t cover costs and can delay care for all patients needing the resource. Additionally, scheduling disruptions can cascade into loss of work for affected patients that thus increase costs to employers. Healthcare expenditures cannot be managed without effective resource planning.

However, it is important to view the Pre-Admission interview as a critical time to introduce (and coordinate) all phases of care including post discharge . A comprehensive approach will create a positive first impression on the patient. 

Patient Service & HCAHPS

Pre-Admissions should start with getting to know the patient. In his book, “Better: A Surgeon’s Notes on Performance,” Atul Gawande states: “If you ask an [unscripted and personal] question, the machine begins to feel less like a machine…” and the patient will feel more like a person, which is the foundation of any good relationship and will contribute to improved HCAHPS scores.

From Quint Studer’s work on admissions through the ED, we have learned that poor patient service is usually not recoverable during the hospital stay and follows the patient out the door. We view Pre-Admission in much the same way. This is the opportunity to connect with the patient and demonstrate the caring nature of the institution through customized, patient centric care.

Patient Safety and Re-Admission

Pre-Admission screening is also a critical time to improve the patient’s general health literacy and understanding of care regimens in order to prevent unnecessary readmissions. Key to preventing re-admissions is medication reconciliation, where existing and future contra-intervening drug therapies are identified and remediated. Patients with low health literacy, low compliance profiles, and complex regimens are most at risk. Failure to identify potential medication errors early is a patient safety issue that can quickly erode a patient’s confidence in the institution and put the patient in danger.

Further, pre-admission screening is designed to uncover co-morbidities (or risks) that can impact treatment and define post discharge follow up regimens. Like medication reconciliation, understanding the patient’s health is a patient safety and a patient satisfaction issue. 

Patient Expectations 

With the advent of high deductible plans and efficacy guidelines, the hospital, the health plan, and the patient need to be in agreement that the admission is necessary and what costs the patient will incur. Identifying financial responsibility may be new territory for hospitals and patients alike. Pre-admission screening can mitigate confusion and surprises – it may not be goods news, but the patient will appreciate being told up front. Further, setting the expectation of the patient and medical team, essentially achieving informed consent with all players, is a critical step to ensuring patient safety.

Pre-Admission Goals

In addition to effective resource utilization, a pre-admission process must improve patient satisfaction and safety. It is not only first impressions that influence patient satisfaction – it is also last impressions. Reinforcing post discharge activities during the pre-admission process can ensure the last impression is positive and the patient has the knowledge needed for a safe recovery:

  • Educate patients on what is going to happen before, during, and after the procedure and what their care responsibilities are at each stage – especially when they leave the hospital.
  • Create a checklist of “needs” to follow the patient through the hospital stay. Synchronize pre-admission and post discharge regimen conflicts that arise from inconsistent additions or deletions in drug therapies (50-90% of re-admissions).
  • Escalatea patient to the appropriate healthcare practitioner and/or setting if additional screening, testing, or clinical care is required.This means integrating 24-hour clinical triage within the pre-admissions process for symptomatic patients.
  • Identify accountability and build patient alerts and a safety net, using a transitional care command center that can span pre-admission screenings, post discharge support, and 24-hour clinical access – such as SironaHealth.
  • Scheduling follow up appointments often starts after the patient leaves the hospital. In most cases those visits can be scheduled in advance and reinforced during the post discharge process. The more lead time, the more timely the appointment (e.g. Operating Room Scheduling).
  • Ensure post discharge best practices are planned in advance – for example, understand patient reimbursement methods and clear the way for a patient to be provisioned by the hospital pharmacy before he or she leaves the building.
  • Document and Discuss discharge care options such as home care, transportation, and drug therapy barriers that can be followed up during post discharge planning, giving the patient time to plan what is going to happen when they leave the hospital. This will allow the hospital to understand what the accountability hand off will be and ensure it happens.

In sum, improving all stages of the patient care cycle (pre-admission, hospital stay, post discharge support) will ensure effective patient resource utilization, patient satisfaction, and patient safety. All three goals will contribute to improved HCAHPS, reduced unnecessary re-admissions, and improved revenue management.

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