Optimal post-acute recovery depends on engagement with patients.

Now more than ever, in the face of COVID -19, the Conditions of Participation for Medicare (CoP) demand that a discharge plan focus on the preferences of the patient or surrogate decision-makers. 

There is solid research backing this concept. People who feel that their preferences for post-acute care have been heard are more likely to follow prescribed regimens. There has been so much written about this that I must leave it to each of you to do your own research. My point is that the new Centers for Medicare & Medicaid Services (CMS) mandates are foundationally solid. 

Navigating preferences boils down to engagement and knowing our patients. 

Through a grant-funded population health management initiative begun three years ago, I and my team got to experiment with patient engagement across the continuum, with the patient-centered goal of effective self-management of chronic health conditions. We discovered that engagement boils down to finding out as much about a patient as we can. The initial assessment explores the resources available to a patient and what barriers there are to optimal recovery: strengths and weaknesses. It is impossible to do this deep dive without finding out what is important to an individual: preferences. This mirrors the interpretative guidance for the 2020 CoP.

What does that look like, in-hospital practice? 

Engage the patient/surrogate however you can. Begin the conversation with questions, not statements. What has your doctor told you about why you were admitted? Did he/she say what to expect? How long will you be in the hospital? Did your doctor say anything about what to expect when you are ready for discharge?

Even if the answer is no, that’s still important information: a chance to teach your patient about their rights to get answers to their questions, and encouraging them to do so. 

After this, dive into what a patient has going for them and against them: resources and barriers, strengths and weaknesses. Every patient presents with something useful toward the goal of optimal recovery: doing the best possible with what is available. Look at their healthcare encounters over the last six months for clues, prior functional status, caregivers, and support systems. Inform the patient of what a usual course of recovery looks like for someone similarly situated. Then, with their help, develop a strategy toward optimal post-acute recovery, whatever that may look like for them.

Why is this especially important now? Because of COVID-19, we will very soon do more with less than ever thought imaginable.

How easy will it be to get a patient into a skilled nursing facility, should the COVID-19 pandemic reach the dimensions predicted? How hard will it be to get home health care, or to see a primary care provider? What answers will you have for patients and families, when so little is available? What skilled care will they have to shoulder? 

We know the answers. We’ve dealt with it before, when, before Medicaid expansion, so many patients were uninsured. You had to dive into the family dynamics, even enlisting the estranged, teaching them how to care for their loved ones, getting them as functionally good enough to move around the house with assistance as possible. You know the drill. It’s the same with a TB patient. Before releasing them to home quarantine, we know all about them, right down to their second cousin, twice removed, if that’s someone with whom they may have contact.

Know as much about your patients as you can, so you can leverage everything available to them. It may not be much, but sometimes good is good enough.

Again, know as much about your patients as you can.

Am I being too optimistic? I hope not. Will we be able to accomplish any of what I’m suggesting? We won’t know unless we try. 

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 has had the effect of bringing us to a realization that optimal post-acute recovery depends on engagement. The patient is not in a position of equal power, but greater power, over their health. We come to the game with superior knowledge. If we get to know our patient as a means to establishing their preferences, the two will find equilibrium. Patient adherence to the prescribed regimen, proven by research, improves, as do concurrent acute-care outcomes. Communication gaps are bridged. In times of extremis, bridging that gap may be the only hope we have, when choices are so limited.

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