Although electronic health records are widely adopted in hospitals and (to less), care coordination remains after acute, coordination of care and monitoring results between both types of service providers often a major challenge.
For example, patients who went out to skilled nursing facilities and other PAC sites test 22.8 % re -acceptance rate The country, compared to 13.9 % For all discharges.
Challenge
Trihealth, a non -profit health system of four hospitals, and a responsible care organization in Ohio with 140 care sites and a network of more than 200 skilled nursing facilities, sought to reduce these re -readings and help patients safely return to their homes.
But the health system had a limited awareness of the health of its patients and its condition in PAC’s facilities due to the old monitoring methods that usually involve sending faxes and making phone calls.
Lori Baker, employee director immediately, said that once patients went out to SNF from a hospital, the vision was in their health and their path limited and inconsistent, which greatly reduces the ability of employees to intervene immediately. Population Health Care Department And the post -acute network in Trihealth.
“This is primarily due to the arduous administrative steps and complex operations required to obtain clinical updates, usually through phone calls and even fax.” “As such, our re -acceptance rate of SNFS was 25 %. Our patients in SNFS were 25 days on average.
She added: “As ACO, we knew that the process of transition and coordination of care after the acute was not a sustainable model if Trihealth would succeed in any program to pay the value -based care in the future.”
an offer
The ACO driving team went to Baker to reduce the acceptance rate from 25 % to 20 %, and likewise, LOS is from 25 to 20 days on average, which, at that time, Baker thought unrealistic.
She said: “To accomplish this, we needed to develop a new cooperation process after the sharpness where our careers can spend a much less time searching for information and updating it in our electronic health record and more time in cooperation with doctors in SNFS to reduce the risk of acceptance of the patient.”
She added: “What we need the care system after our acute care is to provide a vision of what we are used to calling the” black hole “for data. “This means that we will take the patients to SNFS with extensive information about hospital stays and care plan, but it was very difficult to get any information from the facilities. Part of the problem was the need for a platform with easy access to the patient’s information during SNF residence.”
the Sponsorship administration The system will cancel the need for many phone calls, check the fax and wait for updates. It also reduces the need for care managers to collect and enter information manually in the patient’s scheme. This benefit alone will provide tremendous time savings and actual time information.
“Perhaps most importantly, the system will need to provide our care managers, who monitor patients in SNFS and service providers in outpatient clinics, implementable information, not just the patient’s public condition,” Baker explained.
“By a predictive vision of the patient’s risk level and access to in -depth clinical observations, care managers can empty more efficiently in various installations after sharp and give priorities for care for care with doctors in SNFS with higher patients.”
Facing the challenge
A after -year care platform, which provided a simple and mechanical method for the exchange of clinical visions between the care and after -year care management teams
Trihealth has been implemented via 45 after sharp care management platform called PAC Management from the Health Health INT PointClickcare. The platform is integrated into the EHR EPIC system and provides care managers with a full vision of the patient’s care history, condition and path.
“This is possible because the platform connects to the largest health care network in North America, which includes all SNFS in our network,” Baker said.
“Care managers or primary clinic clinics can log in to the system daily to display clinical visions in actual time, provide a comprehensive vision for admission, diversities, status reports, treatment documents, and individual patient clinical data.
“Besides these data, our doctors can see indicators of the risk of re -acceptance and analyze it from the hospital’s predictive algorithm.” “the The algorithm of machine learning It helps to identify patients with an increased risk of re -hospitalization and potential factors that contribute to increased intensity. “
She added that this enables care managers to give priority to patients who need attention and help to simplify clinical management. She said that the new process enhances patient care with increased CMS quality and general performance measures, which leads to network improvements.
results
“Although I believed that the acceptance rate of 20 % was a long period, because the implementation of our acute care management platform, our SNF network admission rate decreased to only 18 %, by 28 %.” “We also reduced the average LOS from 25 to 18 days, a decrease of 28 %.
“Moreover, we calculated our estimated cost savings compared to the ACO standards well and we decided that, thanks to these improvements, we will probably save at least $ 8 million annually.” “I don’t think any of them was possible without the technology we have now.”
Moreover, although there are no difficult results, the work experience of care managers responsible for patient monitoring in SNFS has improved significantly due to low manual data management activities. She said families are also grateful because Trihealth can provide them with data about SNFS because they are usually unaware of all facilities in their area.
Advice for others
Baker recommends health systems that work with large networks of SNFS and other after acute care facilities that must provide any technology by actual time data from these facilities and automate as possible as possible to manual manual management.
“By removing non -clinical duties from after acute care monitoring, skilled and experienced care managers can train at the top of their licenses, identify patients who need interventions, develop the most effective care plans, and cooperate more efficiently with doctors in facilities,” she said.
She concluded that “likewise, Select Select must provide more than just data, but it is a really comprehensive picture of the patient.” “It may be or not the data alone is meaningful, and therefore technology should help collect the pieces together. By providing doctors that seems to be patients with compensation or more vulnerable to communication, patients with higher risk, with higher needs can get interventions first.”
Follow Bill Hit coverage on LinkedIn: Bill Seuiki
Email him: bsiwicki@himss.org
Healthcare is Hosz News.
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