Care Coordination Across the Continuum

The Impact of Real-Time Patient Care Coordination

Care coordination is widely accepted as a cornerstone of value-based care. The promise of improved collaboration among providers, overall improvement in care quality, and ultimately successful patient outcomes are the frequent goals associated with a successful patient care coordination program.

Care coordination is also cited as an effective means to reduce wasteful spending. An article in JAMA examining waste in the U.S. healthcare system cited ineffective care coordination contributing up to $80 billion in wasted spend. Why? Health care is often provided in “silos,” which leads to miscommunication, unclear ownership, fragmented patient care, and frequently poor outcomes, particularly among the most vulnerable populations.

Done correctly, care coordination drives quality outcomes across the care continuum. Common benefits of care coordination include:

  • Lowering ED utilization
  • Preventing hospital readmissions
  • Preventing unnecessary procedures and tests
  • Eliminating medication errors
  • Treating behavioral health problems holistically
  • Identifying and managing social determinants of health

Care Coordination Spotlight

Generations Family Health Center, regional FQHC in Connecticut

Hear from Judith Gaudet, Systems of Care Manager, Generations Family Health Center. “Since day one, PatientPing has improved our workflow tremendously. I was able to develop a protocol and policy within a week and my care coordinator started using it immediately. We are actually pulling people out of the emergency room and getting them into the office to be seen for primary care issues as opposed to utilizing the ED.”

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Patient Spotlight: ED Care Coordination for Dementia

An 80-year-old woman visited the ED four times in a month for a mild heart failure condition, twice requiring hospitalization. When given discharge instructions, she is able to repeat them back accurately. However, she doesn’t follow through with the instructions after returning home because she has not yet been diagnosed with dementia.

Houston Methodist Coordinated Care, a PatientPing pioneer in Texas

Hear from HMCC. “It’s now easy for us to know where our patients are. In our first year, we knew of 383 Skilled Nursing Facility placements but we had 683, so that proved how many placements we did not know about. This year with PatientPing, we’re on track 1-to-1. The other day we noticed we had a patient that was in Connecticut visiting a family member and something happened to them, but because PatientPing is also in CT, we were able to identify that care event.”

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Patient Spotlight: ED Care Coordination for Hyperkalemia

The morning of Kay Edwards’ discharge from the hospital, a potassium level was ordered from the hospital lab; the value, 5.5 – up from 4.2 two days before – was entered into her hospital chart after she had gone home. No one saw the lab value and the updated hospital discharge summary was not immediately sent to her primary care physician (PCP). A week later when the discharge summary reached the PCP, Ms. Edwards had already died of a cardiac arrhythmia, presumably from increasing hyperkalemia.

UI Health, Improving Patient Care Across Illinois

Hear from Rani Morrison, Senior Director, Care Continuum, University of Illinois Hospital & Health Sciences System (UI) Health. “We had a patient admitted to our hospital that was not from the immediate area. He was from a suburb that was quite a bit away, and we couldn’t understand how the patient ended up at our facility. We were able to go into PatientPing and look at his care story to understand previous hospitals he’d been to and discovered he had been assigned to a Federally Qualified Health Center (FQHC). We were able to follow up with his FQHC care coordinator and let them know he was in our hospital and to collaborate on a post-acute plan considering his limited resources, lack of insurance and limited access to care.”

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Patient Spotlight: ED Care Coordination for Heart Failure

A 68-year-old man is readmitted for heart failure only one week after being discharged following treatment for the same condition. He brought all his pill bottles in a bag; all the bottles were full, not one was opened. When questioned why he had not taken his medication, he began to cry, explaining he had never learned to read and he couldn’t read the instructions on the bottles.

HCR ManorCare, a Leading U.S. Provider of Post-Acute Care Services

Hear from HCR ManorCare. “If we have a patient that is with us, goes home then requires rehospitalization or an emergency department (ED) visit, PatientPing notifies us that they are in the ED. We can then contact the family and the hospital to potentially save a hospital readmission. By coordinating care, the patient can go back to our care setting and receive the care they need.”

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Heartland Alliance Health, a non-profit, FQHC in the Chicago-land area.

Hear from Olivia Masini, Associate Director of Clinical Services at Heartland Alliance Health, “We received a Ping on a patient who presented to a nearby hospital. Our team reviewed the patients’ visit history in PatientPing and found that he had been receiving treatment at a nearby SNF and uncovered that he left to receive suboxone treatments, and was afraid to let the SNF know. Since leaving, the patient had also been living in an abandoned building. We quickly reached out to the patient’s Heartland Alliance Health therapist and PCP to schedule follow-up appointments and began a treatment plan. We were also able to transition the patient back to the original SNF to ensure a more stable care environment, and are working on connecting him with housing once he is discharged.”

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Patient Spotlight: PCP leverages up-to-date contact info to connect with unengaged patients

A Georgia-based primary care practice received a notification that an unengaged patient visited the ED and was discharged to a skilled nursing facility (SNF). The phone number and home address listed in the EHR was incorrect, so the practice had not been able to reach the patient. By using PatientPing and insurance claims data, the practice determined that its paramedic partner had transported the patient several times in November, so they were able to obtain accurate contact information as a result. The provider was then able to schedule a drop-in visit for the patient and connect with the manager of the group home to schedule a future visit for ongoing care.

Alcohol, Drug and Dependency Services succeeds with ED Care Coordination

Upon discharge from the ED, an e-notification was sent to a behavioral health organization about one of their patients, a 30-year-old frequent user of alcohol and opioids. Given the patient’s history, his counselor and recovery coach called to check on him at his home. The man was intoxicated, dissociating, and in need of immediate care, so the recovery coach called the police who immediately took him back to the hospital. Since that day, the behavioral health organization has been working with the man. He has successfully completed detox and is currently in inpatient care.

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Care Coordination Services and Systems for All Organizations

Care coordination’s impact is often felt among the high-risk and the most vulnerable subsets of patients, those that suffer from chronic conditions, comorbidities, or mental illness, or patients with health disparities due to economic or racial inequities. In our experience working with hospitals, ACOs, PACs, behavioral health providers, payers, healthcare provider groups and the organizations supporting them, we’ve heard countless stories of how care coordinators connect and care for patients. These stories inspire us and need to be shared more widely so that the front line, practical, patient-centered benefits of care coordination are realized and appreciated.

It’s easy to get caught up in all the promises, research studies, and numbers surrounding care coordination and forget the everyday impact of well coordinated care, or a lack of coordinated care, has on patients and providers. Our goal is to inspire the healthcare community with these everyday stories to break down care silos that cause a multitude of problems ranging from information gaps to duplicative care by shedding light on the impactful work that healthcare providers deliver to their patients every day with PatientPing.

How to Improve Care Coordination, Let Us Show You.

Sharing real-time information, via admission, discharge, and transfer (ADT) events, about patients’ care encounters across providers introduces new levels of visibility for respective care teams.

These notifications include:

  • Relevant information about a patient’s current care encounter
  • Basic demographic details
  • Diagnoses where permissible and available
  • Information about the provider or institution sending the notification.

Therefore, community-based providers can ensure better, safer, and more efficient care transitions. In fact, the Centers for Medicare and Medicaid Services (CMS) recognized the importance of such ADT notifications in supporting patient care and finalized a new Condition of Participation (CoP) as part of the Interoperability and Patient Access Rule (CMS-9115-F). The CoP requires hospitals to share electronic ADT event notifications, or e-notifications, with other community providers, such as primary care physicians (PCPs) and post-acute care providers, to facilitate better care coordination and improve patient outcomes.

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