The effects of the demographic shift in the U.S. are being felt acutely in healthcare, where the rising number of older adults is increasing demand for both post-acute care (PAC) and long-term services. Health systems are struggling to meet this growing demand due to labor shortages, rising labor costs and evolving reimbursement models.
During a July Becker's Hospital Review webinar sponsored by PointClickCare, Cathy Guttman, associate director of value-based care at PointClickCare, moderated a discussion with Lori Baker, director of population healthcare management at TriHealth (Cincinnati), about how organizations can tackle those challenges by improving care coordination, deploying technology and using predictive analytics.
Three key insights were:
1. Organizations need better visibility into the patient journey across the entire care continuum. A lack of visibility exists as patients progress between care settings and levels of care. This lack of visibility hampers efforts to provide optimal care as it limits opportunities for care coordination and collaboration.
A typical scenario occurs when a patient is discharged from a hospital to a senior nursing facility (SNF). When this occurs, the patient's clinical team has no line of sight into when that patient is discharged from the SNF and therefore cannot support that transition. Also, the hospital cannot see when there are complications that may make a patient's readmission more likely.
Guttman described this lack of visibility as a "black hole." "There's lots of information the hospitals don't know that SNFs do," she said. "The black hole is an important part of the care continuum."
2. PointClickCare's technology improves discharge visibility by connecting siloed data. PointClickCare's PAC Management platform transfers electronically relevant patient information from PAC facilities' systems into hospitals' EHR systems, providing real-time information throughout patients' post-acute transitions. "We can look at the patients' notes in the system to see how they are [being managed] and we are able to be a part of connecting their care and services," Baker said.
By using the PAC Management platform, TriHealth reduced readmissions from 25% to 10% and decreased patients' average length of stay at PAC facilities from 25 to 20 days.
3. Through bi-directional data and predictive analytics, PointClickCare enables care teams to proactively follow up with at-risk patients. By surfacing patient data bi-directionally to the hospital and to the SNF or PAC facility, PointClickCare's platform streamlines care coordination and ensures that at-risk patients are prioritized for follow-up and are provided with the right follow-up.
"When the nurse goes into the chart and notices that there are some psychosocial issues or barriers going on, they'll immediately get our social workers involved so that as the patient goes home, our social workers can make a phone contact to address those areas and prevent a readmission," Baker said.
Further, by displaying which patients are trending up or down in terms of care needs, the platform enables nurses to practice to the top of their license and focus on clinical aspects of care rather than on tracking, ranking and prioritizing care transition touchpoints and issues.
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