Staci Porter

Evidence is key to attaining best outcomes outside the four walls of the hospital

February 19, 2021
By Staci Porter

Most hospital-based physicians have a strong sense of the importance of basing patient care on the best available evidence to improve the patient care, standardize decisions, and improve outcomes.

However, caregivers working beyond the four walls of the hospital (e.g., those in the post-acute setting and pre-acute chronic care management setting), face a unique challenge. It isn’t that pre- and post-acute providers don’t practice evidence-based medicine; the challenge is in making this information available in an easily digestible way. It is critical that all members of the care team – including the case manager, prescribing provider, nursing team, physical therapist, occupational therapist, nutritionist – have access to the latest evidence-based recommendations and guidance updated and informed about diagnoses, treatment options and care plans.

The use of evidence-based interdisciplinary care plans is essential to ensuring patients receive proper care and management. The ideal care plan library will include recommended evidence-based guidelines for the testing and treatment of patients experiencing a range of long-term conditions, such as chronic obstructive pulmonary disease, depression, diabetes, and heart failure. Each care plan should be based on a whole-person care approach that considers a patient-centered model to treating physical and psychosocial needs and delivering preventative care.

Why evidence matters for pre- and post-acute providers
Pre- and post-acute caregivers, including those at skilled nursing facilities, rehabilitation centers, long-term post-acute care centers, and population health management organizations, are an invaluable component of the care continuum. These caregivers are dedicated to helping smooth the transition process from hospital to home for patients and their families and keeping them healthy in the communities. They also play a key role assisting hospitals and other providers in preventing avoidable readmissions. In the U.S., it is estimated that one-in-five hospital patients are discharged to post-acute care settings such as skilled nursing facilities or long-term care hospitals.

Post-acute providers’ progress toward value-based care, however, has lagged much of the rest of the industry, as a recent Black Book Research survey illustrates. The survey of 1,640 long-term and post-acute care providers revealed that almost 90% of skilled nursing and sub-acute facilities predicted no shift in the portion of their payments through value-based care models in 2020.

Because pre- and post-acute providers are moving more slowly than their hospital-based counterparts to adopt technology that can ease the transition to value, they risk missing out on the benefits of evidence-based guidelines. Evidence creates the foundation of all value-based contracting arrangements, guiding payers and providers to reach consensus around the treatments and tests that have been scientifically proven to lead to the best outcomes – and, conversely, avoiding the use of unnecessary and ineffective interventions.

“Integrating evidence-based practices through clinical operations can control rising costs, reduce duplication and other inefficiencies, and position the business to be a successful player in the reforming post-acute continuum,” according to Black Book Research.

For example, care plans built upon recommendations from published evidence-based guidelines contain vital information that guides clinician decision-making, with the potential to improve patient outcomes as well as in mortality, cost, length of stay, and readmission rate.

How evidence improves patient care and outcomes
A rigorous, systematic approach to cultivating evidence and incorporating that evidence into care plans can help improve outcomes of individuals who are at high risk for negative consequences. These include poor health outcomes, ED visits, and acute care readmissions. Targeted interventions and proactive management strategies for controlling and alleviating disease-related symptoms and for mitigating risk are key. Empowering providers and health plans to proactively manage patients using a team-based collaborative approach is essential.

As patients and their caregivers are part of the care team, evidence-based engagement techniques help bolster patient engagement in their own care, mitigate non-compliance, and minimize barriers; thus, effectively coordinate healthcare resources and provide community support.

Equally important is the platform in which the content is stored. Caregivers require a professionally developed, user-friendly content management system in which interdisciplinary care plans built upon evidence-based best practices can be customized to the needs of the individual facility.

As healthcare delivery increasingly occurs outside the four walls of the hospital, care teams must find ways to improve collaboration to better manage patients with chronic illness. Accessing evidence via a user-friendly content management system provides the roadmap that leads to enhanced collaboration and care coordination.

About the author: Staci Porter, MSN, RN-BC, is a senior clinical strategist at Zynx Health. In her spare time, she enjoys the mountains and being outdoors with her naughty puppies a Corgi and Springer Spaniel. As new empty nesters, she and her husband are looking forward to investigating the culinary aspects of zoodling and happy hours in their new home of Palm Springs.