old woman smiling outside
Catalyst Project: Aging

Care transition is a highly important and complex challenge in today’s care continuum. Particularly the elderly and patients from economically less privileged background struggle in todays fragmented and insufficiently coordinated clinical pathways after hospital discharge, causing substantial hardship for patients, relatives, caregivers and other stakeholders (i.e. payers, industry) alike.

Partnering with the University hospital of Basel, Basel Area business & Innovation has engaged on a project to identify the most pressing challenges in today’s care transition and collaborate towards both short- and long-term solutions.

The project’s kick-off on October 30, 2020 was conducted as a virtual multi-stakeholder workshop. Participants included senior staff members of various hospitals in and around Basel, home care organizations, public institutions and health departments, pharma, insurance, as well as digital health startups. This allowed the group to access a wealth of know-how and daily experiences in clinical, nursing, research, social work, and business and management-related challenges.

First, four breakout groups worked on distinct topics that pose a repeated challenge in today’s care process:

  • wound treatment
  • frailty / polymorbidity
  • psychiatric patients
  • oncology
Care Transition

In a first step, the groups sketched the different stages, locations and events of the corresponding patient journey, to then list common challenges in each of these journeys. Some of the most important challenges were:

  • Clinicians responsible for discharge at hospital level have insufficient information about who will provide what level of care at home – resulting in fluctuations in the standard of care and provoking adverse events, including rehospitalizations. High staff fluctuations exacerbate the problem.
  • Some patients are unable to process the information they are given at discharge, resulting in confusion and hardship. After discharge, it can be incredibly hard or even impossible for patients and relatives to reach the right person, as responsibilities are dispersed and expert clinicians may be unavailable for days.
  • In some instances, home care organizations are required to advance specialized equipment out of pocket, leading to frequent gaps of several days in the care continuum.
  • Insurers are confronted with rising costs in chronic care, but have only limited room to support novel treatment pathways outside the current standard of care. At the same time, current reimbursement pathways make it incredibly hard to employ value-based-healthcare

After discussing the specific clinical pathways above, the discussion focused on addressing three of the most frequent overall challenges to elaborate on short and long-term solutions:

  • Flow of information
  • Costs of care and reimbursement
  • Engagement of patients and relatives

Flow of information

  • Long term solution: a central access point for patients, relatives and clinicians coordinating all care activities after onset of a disease, including patient-friendly documentation and coaching chronic patients through their journey.
  • Short term solution: All patient-related documentation is sent to patients by default, without having to inquire at first – resulting in more informed patients with a higher level of ownership and engagement

Costs of care and reimbursement

  • Long term solution: massively simplified reimbursement pathways funneling caregiving towards value-based-healthcare rather than fee-for-service-dominated activity
  • Short term solution: Proof of concept to bundle fee-for-service charges into lump sums, conduct value assessments and generate data as a basis for moving towards value-based health care

Engagement of patients and relatives

  • Long term solution: political awareness changes regulatory and reimbursement pathways in order to incentivize and pay for care coordination and patient communication, including by non-clinical staff
  • Short term solution: Engage in advanced care planning and involve patients and relatives in most important aspects early on in the process

As a next step, three different working groups will engage in selective deep-dives and information-sharing within their organizations. Coordinated by a designated group leader, each group will present their progress in designing, planning and implementing the short-term solution in a proof-of-concept.

Workshop learnings