The following is a guest blog post by Michael Ipekdjian, Director of Customer Success at CarePort Health.
Historically, hospital care teams have had limited visibility into what happens to their patients outside of their four walls—whether that’s stepping down to skilled nursing, being supported by home health, or even returning to the community without any additional services. Quite frankly, hospitals haven’t had much incentive to follow their patients post-discharge. But the playing field has changed with ACOs, value-based programs like BPCI-Advanced, and risk-based contracting. Hospitals are now being held accountable for what happens to their patients in other care settings and in the community, and many are struggling. In this article, I’ll discuss the current barriers to tracking and monitoring patient activity and explain how tools that are driven by real-time clinical data can remove them. I’ll draw on my previous experience as a care management professional and use a real-life patient scenario to show the significant impact real-time data can have on clinical outcomes.
Overcoming the Barriers to Tracking Patients: Nancy’s Story
When I was the director of transitional care management at a community health system, we were in risk agreements with several commercial Medicaid plans, and under these agreements, we were held responsible for thousands of patient lives. Take, for example, Nancy, a high-risk patient who my team worked with closely. She was 53-years-old and living alone in an apartment. She had no real support system and no family in the area. She had two challenging health conditions requiring complex medical management, diabetes and congestive heart failure. Nancy was admitted to the hospital several times a year for acute episodes and also visited the emergency department (ED) frequently. She often went outside our system to other hospitals, which made her activity very hard to track. We knew that she was landing in EDs more than 20 times a year and suffering declining health, but our ability to help her was limited by the tools we had. There were three main challenges we faced with Nancy, which we were able to solve with a technology solution that provided real-time data. This deeper level of insight into Nancy’s care ultimately provided her with the support she needed to limit her inpatient stays, end her ED overutilization pattern, and improve her health.
Challenge #1: Delays in receiving patient data
Like most hospitals, we were reliant on claims data to understand how Nancy and our other high-risk patients were faring. The problem with claims data is that it typically doesn’t come in until 90 days or more after a health event, when it’s too late to intervene. By the time we were aware that Nancy had logged another ED visit at a local hospital, she would be long gone, and we would have only a limited understanding of the care she had received. That was the best-case scenario. I’m sure there were some ED visits that we never even knew about.
Solution: Once we brought on new technology that was powered by real-time data and specifically designed for tracking patients across care settings, we gained insight into the other hospitals and care locations where Nancy was receiving services. Our care management team received alerts every time any of our patients were admitted, discharged, or transferred. That gave us the ability to intervene and redirect care as needed. For example, on the few occasions when Nancy was admitted to another hospital, we knew right away and were able to come up with a plan for her transition out of the hospital prior to discharge, whether that was scheduling a visiting nurse to come to her apartment or sending her to a post-acute care facility to continue her recovery.
Challenge #2: Lack of effective data management tools
Our care management department was comprised of several dedicated FTEs whose primary goal was to move the needle with high-risk patients like Nancy. The team spent most of its time making phone calls, leaving voicemails, and sending faxes, all in an effort to track patient activity. We must have made hundreds of phone calls for Nancy alone. We were gathering data on where our patients were being treated and the kind of care they were receiving and using spreadsheets to organize it. This manual data collection strategy was arduous and time consuming, but it yielded more actionable data than claims, so it was worth the effort initially. Once the number of patients the team was responsible for grew from about 20 or 30 patients per case manager to more than 200, we could no longer sustain this level of manual work. As the size of the patient panels grew, our spreadsheets became unwieldy and it was impossible to analyze the data in a meaningful way.
Solution: With our new real-time technology platform, we were able to look at Nancy’s hospital admissions and ED visits in aggregate and finally get answers to questions like these: What were the main triggers for her ED visits? Which facilities did she frequent most often? What supports post-discharge were most effective in keeping her out of the hospital? How often was she even being discharged with support in place? Within a few months, we were able to develop an evidence-based plan for engaging and educating Nancy. We set her up with a visiting nurse to monitor her blood glucose. We scheduled the appropriate PCP and specialist visits for her and arranged transportation so she could actually get to these appointments. The real-time data platform was effective at the population level as well. We were able to organize our patients into cohorts based on their risk factors and disease states and assign case managers to follow specific populations and develop custom care plans.
Challenge #3: Poor user experience and siloed platforms
Our team had been working in about seven different technology systems. The systems weren’t particularly user friendly, they didn’t talk to each other, and they weren’t capable of pulling in data from facilities outside of our health system’s network. That’s why we were still relying on the phone and fax as our primary tools to track down Nancy and other patients. Our inboxes were flooded with task reminders and notifications from all these different systems, and my staff would waste hours resolving them. Everyone was frustrated.
Solution: Because the real-time data technology platform we selected was both user-friendly and EHR-agnostic, we were able to consolidate our systems and focus on just a few. We could access information about patient activity quickly and with ease. We could click on Nancy’s name and bring up an updated timeline with all of her activity, both within our network and outside. That timeline was key to our understanding of what was bringing her into the hospital over and over. Case managers could also bring up reports showing the activity for all of their patients, and this was helpful in identifying trends among certain cohorts.
Let’s go back to Nancy and how gaining access to real-time data directly impacted her health. This patient had a history of being resistant to preventative services, of overutilizing the ED, and of falling so ill that she had to be hospitalized several times a year. Today, she has become an active participant in her care, calls her PCP or nurse navigator prior to going to the ED, and has been paired with a behavioral health counselor who specializes in caring for medically complex patients. Within the span of two years, we reduced her number of hospital admissions per year from five or six to zero. We reduced her number of ED visits from more than 20 to just a handful. And Nancy is just one patient. Imagine the impact real-time data can have on an entire population.
Michael Ipekdjian, Director of Customer Success at CarePort, is a former bedside nurse and inpatient acute case manager, and has also held multiple senior care management roles. He holds an MBA in Healthcare Management from Western Governors University. Prior to joining CarePort Michael was the Corporate Chief Operating Officer of BetterHealth Your Way. He also served as Director of Transitional Care Management at Holyoke Medical Center.
About CarePort Health
CarePort Health provides care coordination software solutions to manage patient transitions across the continuum. The end-to-end platform bridges acute and post-acute EHRs, providing visibility for providers, payers and ACOs into the care that patients receive across care settings so that all providers can efficiently and effectively coordinate patient care. Follow us on LinkedIn & Twitter. To learn more about CarePort and its full suite of solutions, please visit them online at www.careporthealth.com.