Care coordination and real-time communication close gaps in care

Posted - 2019-02-20

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Care coordination and real-time communication close gaps in care

By: Tim Carey

Elderly patients commonly see several different providers each year, and those with chronic conditions or serious illnesses may be receiving care at a number of unaffiliated facilities such as primary care clinics, emergency rooms, hospitals, rehab facilities and home health agencies. It’s a complex population, which means care transitions and the way patients experience them must be seamless.

Some of the care coordination challenges that we face center around data integrity. When we meet with our partner organizations, there are times when our data on patients’ care events don’t match up. For example, we recently met with a hospital and an ACO that both monitor patient events in EHRs. The hospital and ACO saw that documentation showed one patient was discharged home with VNA services, when in reality, that patient was receiving care at one of our SNFs. This fragmented data for the hospital and ACO creates many challenges, especially for the clinical staff members who are responsible for following patients during their care journeys.

Better communication supports our mission

At BaneCare Management, we’re driven to create an environment built on compassion, dignity and respect for residents and their extended families, as well as for the community and staff members. One of the ways we do that is by focusing on care coordination and real-time communication, especially when it comes to a patient’s status as he or she transfers between care settings.

In 2014, we implemented PatientPing. The tool enabled us to see if our patients were part of an ACO and what services and organizations they had been accessing prior to admission with us. In 2018, we also started receiving “Pings” on our patients, which provide us with real-time notifications whenever our patients receive care after leaving our SNF. This feature has helped us strengthen relationships with other organizations in the community because providers can collaborate more closely to reduce readmissions and help get patients to the right care settings at the right time.

Standardization supports process improvement

PatientPing’s comprehensive care coordination platform lets us see the big picture and follow patients as they move from care setting to care setting. This was complicated for us, as it is for many organizations.

Before joining BaneCare, I was a business analyst at a local community hospital. To find information on SNF readmission rates, I had to go through a very long and time-consuming process to get them. Using a care coordination platform easily gathers information and pulls these analytics for us.

Care coordination reporting is improving all the time, which helps us to standardize our required monthly reporting. We can see admission activity, average length-of-stay and 30-day readmission rates. This helps us to standardize and automate the reporting process between organizations across the continuum.

We use the platform for process improvement efforts, too—specifically to monitor patients presenting to a hospital after they have been discharged from a SNF. It’s important for us to identify the reasons for admissions so that we can improve our discharge planning processes. At BaneCare, it’s all about continuous improvement. We rely on data to help drive those efforts.

Real-time tracking helps close care transition gaps

Our facilities get notifications as soon as a prior patient presents to a hospital emergency room. From there, we’re able to work with that hospital in real time, and direct patients back to SNFs when appropriate, rather than admitting them to the hospital unnecessarily. This collaboration helps to not only reduce unnecessary readmissions, but also improves the care provided to patients by getting them to the right care setting at the right time.

Better reporting and analytics allow us to bridge the gaps in care transitions. For example, in some of our sites receiving Pings, we have been able to reduce our readmission rates by 30 percent to 48 percent.

Looking to the future of care coordination

Working with other industry leaders to improve healthcare is important, too. I recently joined PatientPing’s User Council, which brings peers together with the company’s product development team to discuss user workflows and share feedback on new and upcoming features. As a member of the council, I love collaborating and sharing my ideas with other data-savvy users across the nation.

I know we can leverage health IT to solve many of the challenges we face in healthcare and to improve quality and patient safety, reduce readmissions, improve patient satisfaction and more. Taking a comprehensive approach to monitoring and improving care transitions and closing gaps in care is one piece of that puzzle.A

Tim Carey is director of data and performance analytics at BaneCare Management, which operates 12 skilled nursing facilities throughout Massachusetts and is a trusted family-owned senior services company that has been a leading provider of rehabilitation, skilled nursing, assisted living and adult day health for nearly six decades.



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