PLANNING THE

NEXT SITE OF CARE

AS THE FIRST PRIORITY
WHITEPAPER BY SOUND PHYSICIANS
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When was the last time you heard about a patient

whose goal was to stay in the hospital longer than
necessary and return to the hospital as soon as
possible? Delays in being discharged are not due to a
desire to stay, and readmissions are rarely planned or
voluntary.   But both are often caused by confusion,
concerns, and barriers related to when, how, and where
the patient receives care next.

It’s critical to start the hospital stay by keeping our

patients’ best interests and goals for discharge at the
top of the list of priorities. Aligning patients, their
families, the hospital, and physicians toward the goal of
discharge to the right setting without unnecessary
delays is key to delivering better care – and a better
experience for the patient – at lower cost.   It’s just the
right thing to do.

However, achieving a timely transition of care while

simultaneously lowering the risk of readmission remains
one of the toughest challenges in the quest for value-
based outcomes. It requires clear, proactive
communication and alignment among all who are
involved in the acute “episode of care” – from the first
day of an inpatient admission through the entire post-
acute period.  It’s important to note that during this
episode, on average, 38% of spending is related to
skilled nursing facility utilization and readmissions. The
hospitalist is positioned to lead – from the start – the
conversation and plan for transition to the appropriate
next site of care. The hospitalist keeps everyone on the
same page and sets consistent expectations versus
varied (and sometimes conflicting) perceptions among
patients and their families.
 
Importantly, hospitalists’ planning for the entire episode
of care enables the primary care physician to see the
benefits of what occurred in the hospital and supports
them as they take over seamless management of their
patient back in the community setting.
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A Model for Successful Transition of Care

Engaged Hospitalists

Success depends on engaged hospitalists who build trust with patients and families, and alignment with
specialists, primary care physicians, as well as inpatient and outpatient facilities to achieve the best clinical
outcome for that patient in a value-focused way.

Keeping physicians engaged depends upon aligning care models and reimbursement incentives in support of
what is in the best interests of the patient, rather than in support of the quantity of patients or procedures.
Hospitalists need time to participate in multidisciplinary rounds and care team huddles, proactively plan the
transition with the care management team.

At the time of discharge, they need time to address questions and clearly document and create holistic plans of
care. They can clarify how medications may have changed and anticipate other factors that may impact the
patient post-discharge.   Finally, they need time for a considered handoff of clinical care to the next provider
and/or PCP or specialist.

Resources and Technology

Clinically validated best practices that focus on the whole patient in a value-based approach are needed to
support physician decision-making in real-time.   Clinical processes that are embedded in physicians' daily
workflow technology can ensure consistency and efficiency in doing the right thing for patients. But to be clear:
technology must make it easy to do the right things, as opposed to making it more complicated or more time-
consuming.

Sound Physicians’ proprietary technology platform, SoundConnect, was built specifically to be put in the hands of
our clinicians. From the point of admission, SoundConnect prompts clinicians to start advanced care planning and
goals of care conversations. This allows our clinicians to be proactive in making next site of care decisions and
helps to optimize the use of high-quality networks. Furthermore, SoundConnect allows for communication with
patients’ primary care providers to ensure continuity of care.

High-Quality Networks

Too often, discharge destination decisions are reactive, based on the availability of beds or subject to referral
patterns that may not be grounded in value or measurable outcomes.   Overcoming this requires established
relationships with a network of high-quality post-acute providers, facilities and home health resources in the
community. It is important to follow a transparent and rigorous process for evaluating facilities and then working
collaboratively with them to plan for each patient’s transition and treatment.
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Starting with the End in Mind

When the hospitalist team “starts with the end in

mind,” the path from admission to transition
consistently leads to shorter stays and fewer
unnecessary readmissions. Instead of frustration and
confusion, the journey produces greater satisfaction
for our patient, their family, and the primary care
physician. As this model continuously improves, we
see that the approach that works at the individual
level translates to positive outcomes for an entire
population.

About Sound Physicians

Founded in 2001, Sound Physicians is a national

physician practice organization with a proven track
record of improving quality, satisfaction, and financial
performance for its partners nationwide. We deliver
results under risk-based payment models by engaging
our physicians and advanced practice providers in a
holistic value-based clinical model that spans hospital
medicine, emergency medicine, critical care,
anesthesia, telemedicine, and physician advisory
services.

To learn more about how Sound Physicians is

partnering with payers, ACOs, and other risk-bearing
physician groups, email us at:
partnership@soundphysicians.com.

Quality | Service | Teamwork | Integrity | Innovation