Smart Assistant to Reduce Post-Discharge Readmissions

Background

Patient discharge planning is a legally mandated function for hospitals in the United States. It is also one of the “basic” hospital functions outlined in Medicare’s Conditions of Participation from Centres for Medicare & Medicaid Services. The need to establish an effective discharge planning policy and guideline has been given attention, together with the trend toward starting the discharge planning process upon admission, adopting a multidisciplinary approach, and coordinating post-discharge care support.

Post-discharge readmission among Medicare patients

• 19.6% readmitted within 30 days
• 34.0% readmitted within 90 days
• Costing $17.4 billion annually

Reports indicate that up to 40% of all medication errors can be traced back to insufficient medication reconciliation during the transition of care (source).

Problem Statement

The complex process of transferring a patient from one care setting (e.g., a hospital or nursing facility) to another often leads to confusion about treatment plans, missed follow-up appointments, patient dissatisfaction, and non-adherence to medication schedules. These causes result in unnecessary readmissions. 

Goal

When patients become more informed and start to feel like part of the care team, they feel comfortable asking questions, raising their concerns, and proactively taking up their post-discharge duties. This is a simple solution to provide patients with more meaningful interactions while building deeper relationships, establishing trust, and ultimately establishing their commitment to better health in the long run.

Designing a centralized, digital platform that brings together all participants involved in post-discharge care that engages and supports patients throughout their entire healthcare journey.

UX Strategy

Effective discharge planning is key to limiting medical errors during transitions of care from hospital to home – a time during which patients are particularly vulnerable. The ideal scenario for effective care involves the patient and emphasizes their complete education and active participation.

Design Proccess

At Koru, our design process focuses on improving usability, accessibility, and delight in product interactions. Keeping the user in the center of the creative process leads us to create designs that are clutter-free, easy, intuitive, scalable, engaging, and provide a fabulous experience to the users.

Research

The research phase of the process began with in-depth data gathering. We started by conducting user interviews. This, along with periodic consultations with stakeholders helped collate information that helped in forming user personas and a typical patient journey map.

Ensuring active patient participation in their post-discharge care requires an ecosystem that facilitates building a relationship of trust and seamless communication amongst all three participants, i.e., the patient, clinician, and admin. The process begins with addressing their combined essential needs.

Synthesis

Most of the rapid readmissions to the hospital appeared to be avoidable and yet represented a major health scare for the patient. There was a lack of a well-connected system to keep the patients engaged throughout their healthcare journey as well as inform clinicians of what required their timely intervention.

Ideation

Regular and efficient post-discharge check-ins have a two-fold advantage

• They help catch complications early and mitigate growing issues, thus keeping patients out of the hospital.
• Reducing hospital readmissions have positive financial outcomes for healthcare organizations.

Design

Workflow configuration and monitoring for Admin
Multiple, pre-configured, automatic workflows, designed to cater to numerous healthcare use cases, that enroll all patients and keep them engaged in their health.

• Ability to track patient engagement performance for every workflow.

• A drill-down view to analyse and tweak patient touch-points and modalities.

NLP-powered conversations with chatbot for Patient
A bot that engages in conversation with patients, with empathy and purpose, providing just the right amount of nudge to the patient.

• The bot allows learning in a meaningful way to enable clinicians to make informed decisions and take timely action.

• Pre-prioritized queue balanced with enough manual control for user to decide which alert they want to act on vs ignore.

Interface for Clinicians to give focus and clarity amongst the chaos
Meaningful User Interface designed to present right amount of information in a way that aids decision making and allows the clinician to focus and act.

• A chat history to further understand the alert and build context.
• A pre-prioritized queue based on numerous logic and rules saves the clinicians laborious and faulty manual prioritization.
• Right kind and amount of data points to tellclinicians what triggered the alert, how critical it is and what can be done.

• Snapshot of patient journey presented as a timeline, empowering the clinician to make meaningful conversation with patients when they reach out.
• Ready way to reach out to the patient, with an insight on which modality will generate the response.