Throughout my years practicing as an RN Case Manager, I can attest to the often heart-wrenching challenges of families trying desperately to find the best care for their loved ones during unexpected, tumultuous health circumstances. Picture the frequent scenario where Mom is living alone, managing her life quite nicely with the support of family and friends, and suddenly she experiences an adverse health event – a fall, a new diagnosis, or a complication of her chronic illness that lands her in the hospital.

The family rallies its troops to coordinate plans to provide the support and strength needed to allow Mom to return to her prior level of independence at discharge. They rely on the resources of the hospital to help them craft the discharge plan. Namely, they look to the Case Manager for information on where to go, what to do and when to start the process. Every day, family members ask, “Can you please just let me know the best resources available for my mom to help her safely return home after discharge?” You’d think the answer would be, “Sure, together let’s research the best options based on readily available, accurate qualitative and quantitative data.” Unfortunately, most of us can’t say that. The data simply doesn’t exist and where it does, it’s stored in multiple, disparate siloes making it impossible to manage across a challenging patient census.

We are a data driven society. We research nearly every purchase, large or small before making a buying decision. We pour through Google searches, Consumer Reports, Amazon, etc., etc. to identify the best value for our money. We wouldn’t consider purchasing a car, a bike or even a skateboard without understanding the pros and cons of the item. Why then are we willing to accept the lack of performance, outcome and cost data on such personal, life-changing decisions as selecting the highest-quality care providers for ourselves and our loved ones?


Work In Progress (A Common Phrase in Healthcare)

We’re certainly making progress in several areas along the healthcare spectrum; hospitals and physicians are increasingly being ranked by organizations like the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare and Physician Compare websites and third-party reviewers like Healthgrades, ZocDocs, WebMD and others. Where we lack clean, accurate and reliable data is in the post-acute care arena - home health and private duty agencies, durable medical equipment companies, infusion, dialysis and wound care centers, assisted living facilities, etc. This integral part of the care continuum has largely been ignored despite its significant impact on quality of life as well as the sheer volume of the population requiring care. According to the U.S. Department of Health & Human Services, 70% of people turning 65 will utilize some form of long-term care during their lives whether skilled or custodial care, facility or home based, or community support services.

Post-acute care data decays rapidly, rendering it nearly useless to those of us who rely on current and complete information to execute optimal care plans for our patients. This data deficiency has historically resulted from a lack of standardization of healthcare data including cost and quality metrics on services outside the four walls of the hospital. The post-acute data issue is further exacerbated by high levels of staff turnover within these organizations, antiquated or absent technology and negligible operating margins with little wiggle room to invest in analytics. However, in the fee-for-service world, a hospital’s accountability for the patient ends at discharge, so the lack of post-acute data, while frustrating, doesn’t impact the hospital’s bottom line. As long as the Case Manager documents a safe transition plan to the next level of care, there will be no penalties imposed if the patient returns to the hospital due to a complication or discharge failure.


The New Post-Acute Paradigm –  It’s All About Outcomes

The advent of value-based care, including CMS’ Hospital Readmissions Reduction Program, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare Bundled Payments for Care Improvement Initiative (BPCI) and other government and private payer value-based models, is turning the industry on its head. Providers along the entire care continuum must collaborate with each other and share data to help improve care transitions, care delivery, patient outcomes and the patient experience or face stiff financial penalties, patient dissatisfaction, provider disengagement and a breakdown of the system.

The aforementioned initiatives represent only the tip of the iceberg for the healthcare industry in terms of new regulations, new models of care and the resulting new data requirements to validate program effectiveness. I’m hopeful the proposed changes to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) will soon be a reality. This act, designed to improve transparency and patient experience during the discharge planning process, will require hospitals and post-acute care providers “to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences”. 

That all being said, I’m confident that every hospital, payer or other risk-bearing entity, family member, and patient would agree that a unified, comprehensive database of current medical and non-medical services and the corresponding financial arrangements and quality indicators is a necessary component to achieving the best medical, behavioral and social outcomes for those we serve. Since I left my role as a hospital discharge planner in 2012, a wide variety of new applications and databases have emerged as potential solutions to this dilemma.

In fact, it is now possible to imagine a world where Mom’s transitional healthcare needs are carefully and deliberately matched to providers through real-world, evidence-based data.

Can your organization provide this needed service for your patients?

Please feel free and reach out to me directly to share your own experience in optimizing care within the realities of healthcare today. I’d love to hear how your organization is helping to accomplish this lofty goal while traversing the rocky road to value-based care.


Contact Carelike to help improve the efficiency of discharge care.


For more information about Carelike, please contact Katy Weisbrodt:

O: (404) 250-8376   |   C: (770) 851-8653   |   |

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 


Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination.