Improving Care Coordination and Outcomes Monitoring in Post-Acute Care Facilities
Despite the widespread adoption of electronic health records in hospitals and post-acute care facilities, challenges in care coordination and outcomes monitoring persist. Patients discharged to skilled nursing facilities (SNFs) and other post-acute care (PAC) sites face a higher readmission rate compared to all discharges, highlighting the need for better communication and collaboration between providers.
The Challenge
TriHealth, a not-for-profit health system and ACO in Ohio, recognized the need to reduce readmissions and improve patient outcomes in PAC facilities. However, limited visibility into patients’ health status at SNFs hindered timely interventions and care coordination. Outdated methods like phone calls and faxes made it difficult to obtain clinical updates, leading to a high readmission rate and prolonged length of stay at SNFs.
Proposal
To address these challenges, TriHealth aimed to develop a new post-acute care collaboration process that would streamline information exchange and enhance care coordination. By implementing a post-acute care management platform, the organization sought to provide care managers with real-time clinical insights and predictive analytics to identify high-risk patients and prioritize interventions.
Meeting the Challenge
TriHealth partnered with PointClickCare to implement a post-acute care management platform integrated with their Epic EHR system. This platform enabled care managers to access comprehensive patient information, including admissions, discharges, status reports, therapy documentation, and predictive risk indicators. By leveraging machine learning algorithms, care managers could efficiently triage patients and collaborate with SNF clinicians to prevent readmissions.
Results
Since implementing the post-acute care management platform, TriHealth successfully reduced the readmission rate from SNFs to 18% and decreased the average length of stay to 18 days. The organization estimated cost savings of $8 million annually and improved overall performance in value-based care programs. Care managers reported enhanced working experiences and increased efficiency in patient monitoring, leading to positive feedback from families.
Advice for Others
Lori Baker, Director of Population Healthcare Management at TriHealth, advises health systems to prioritize real-time data exchange and automation in post-acute care monitoring. By empowering care managers with actionable insights and holistic patient information, organizations can improve care coordination and outcomes in PAC facilities. Selecting technology that goes beyond data to provide meaningful insights is essential for driving positive patient outcomes and reducing healthcare costs.
Healthcare IT News is a HIMSS Media publication.
