Tracking patients beyond the hospital

Listen to this article

Health care providers recognize that the ability to monitor patients’ health once they leave the hospital and enter a skilled nursing facility can improve outcomes and help lower readmission rates.

Because reducing readmissions is so important for hospitals, finding ways to prevent them is vital. And the shift to value-based being driven by the government and health plans is the biggest impetus for hospitals to look for tools that will help them collaborate effectively with downstream providers.

Cooper University Health Care’s Accountable Care Organization AllCare Alliance, has adopted technology to help providers and patient care coordinators closely monitor patients by giving them the ability to intervene in real-time if the patient has a health crisis.

Technology from Boston-based CarePort allows Cooper to track a patient’s progress after discharge from the hospital while at the same time giving payers the ability to recognize how the patient is progressing in a post-acute facility.

CarePort is a software that interfaces into the nursing home’s software and then provides alerts to us through our software to our case managers and social workers, care coordinators and health coaches. They can get daily alerts when our patients are going into a skilled nursing center so we can coordinate their care throughout their skilled nursing stay and when they discharge.

– Elizabeth Nice

The system can also aggregate meaningful and actionable data that provides health care entities, hospitals or accountable care organizations the ability to track progress at the facility and monitor performance in the post-acute care network.

Elizabeth Nice, executive director AllCare Health Alliance said anytime you transition from one level of care to another it poses a high risk for problems including readmissions.

“CarePort is a software that interfaces into the nursing home’s software and then provides alerts to us through our software to our case managers and social workers, care coordinators and health coaches,” Nice said. “They can get daily alerts when our patients are going into a skilled nursing center so we can coordinate their care throughout their skilled nursing stay and when they discharge.”

If the patient needs to go, back to the emergency room, providers at Cooper are alerted enabling them to give the emergency department a heads up so they can provide them with vital data on the patient.

The technology also allows providers to make sure that patients transition to home safely and that they are getting the services and the follow-up care that they need which Nice said can help them recover more quickly.

In the past Nice said that patients could be discharged from a skilled nursing center and providers may not know it. The patient might be sent home without oxygen for example. Now Cooper nurses are alerted and can follow-up to make sure that the patient has what is needed.

Demand for technology

Dr. Lissy Hu, CEO and founder of CarePort, said many of her customers are part of ACOs or are implementing value-based care programs where financial reimbursement is tied to overall health status.

“In the past, hospitals have been paid based on volume. ACOs and other new programs are changing the paradigm. They incentivize hospitals to take the long view on how to keep you well rather than just the number of procedures they can bill for in a given year.”

Hu said that to be successful, hospitals need visibility beyond their four walls. She added that CarePort connects hospitals electronically with downstream providers such as nursing homes and home health agencies so that no patients fall through the cracks.

CarePort enables the doctor who repairs a broken hip in a hospital to be connected to the nursing home where the patient is getting rehab. “Our goal is to ensure that everyone who is caring for the patient is on the same page,” Hu said.

“It’s always been the right thing to do for a patient since most patients receive care from multiple providers. Now there are reimbursement models to justify investments in care coordination across the continuum. And with the aging of the U.S. population, we’re going to see that trend continue into the future in a big way,” Hu added.

Hu said that her customers cover the spectrum of healthcare providers and include ACOs, health systems, community hospitals, physician practices, and post-acute care providers.

Nice said that with CarePort’s technology health care providers could see things that they have not been able to see in the past.

“It gives us much more of a partnership with our skilled nursing facilities because we have some more insight. We are having an ongoing conversation rather than surprises. Now we know where people are, we know what their next step is and we know how we can intervene to make them have a successful transition.”