The Ever-Expanding Discharge Summary

December 7, 2015 Streamline Health

By Casey Kozee, Senior Solutions Manager, Streamline Health, Inc.

I recently ran across an announcement that I found to be quite interesting.

On November 3, 2015, the Department of Health and Human Services (HHS) released proposed requirements for discharge planning for hospitals participating in Medicare and Medicaid. And, the requirements would implement changes from the Improving Medicare Post-Acute Care Transformation Act of 2014. Public comment is open until January 4, 2016. We can expect new rules to go in effect sometime in late 2016 or early 2017.

The HHS has focused on reducing complications and adverse reactions that may occur after discharge from the hospital and may require readmission. Readmissions are bad for patients and hospitals alike. The HHS has realized that one important—and in some ways, very simple—step that can help is to provide more complete information to all stakeholders in a patient’s discharge. This information is provided through the Discharge Summary documentation. The HHS recognizes that the average length of stay has decreased significantly since the current federal requirements for Discharge Summary information were established. Now, there are even more factors to consider in providing the best possible information to patients and other post-discharge caregivers such as nursing homes and skilled nursing facilities.

This sentence from HHS sums up the new view best:
‘We propose to require that the discharge plan be tailored to the unique goals, preferences and needs of the patient.’

In order to achieve the goal of providing Individualized Discharge Summary information, providers will need a robust Enterprise Content Management (ECM) system that can store documentation at the patient encounter- and recurring visit-level. To highlight the power of tailoring the Discharge Summary information—and appreciate why an ECM is needed—consider the new realities of dealing with patients in today’s market. For young, relatively healthy patients, you’re simply tracking data on post-visit care and follow-up appointments. However, when managing the patients who represent the greatest readmission risk, you have a much more complex scenario. Consider the challenge of creating a Discharge Summary for an elderly patient with multiple co-morbid conditions, a long history of surgeries, substance abuse, multiple medications and mental health disorders. Then consider the fact that these patients tend to receive care from multiple providers, which means care documentation may come from several different systems. It’s easy to see how important the ECM system is to bringing together all the right information.

The proposed HHS requirements highlight the increased role that ECM systems can play in improving healthcare. Processes and procedures are changing rapidly to support better outcomes and more efficient and less expensive episodes of care. The underlying foundation to implement all of these changes is Health Information Management (HIM). Information must flow easier and more completely throughout the hospital and beyond in order to truly realize improvements in care. An Enterprise Content Management system is the key to making this happen.

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