Three Takeaways for Coordinating Post-Acute Care

In the latest in our series of webinars on post-acute care, we discussed “Coordinating Care After Patients Leave the Hospital.” This month’s installment was led by our guest speakers Nathan Mast, post-acute strategist, and Ron Drees, director of post-acute services, at Mercy Health. Nate and Ron discussed the importance of having a connected network of providers that collaborate around care coordination – and how the outcomes of such a network are positive for both providers and patients. 

Here are three key takeaways from the webinar. If you want to listen to the webinar in its entirety, you can find it here.

Communication is difficult, but not impossible, especially if everyone has the right information.

Communication is hard, and made more difficult with complex cases. How to manage patients across the continuum is high on everyone’s list not only because it’s the right thing for patient but because CMS is pushing providers to work together as patients move across the continuum.

It is particularly difficult to communicate around bundled payment patients, mostly because even identifying those patients, let alone make sure they get into appropriate facility, can be near impossible. Having information about patient participation in these kinds of programs at the fingertips of care coordinators – and post-acute providers – is key. Having an automated way to identify these patients is even better. 

Use data to establish and grow relationships with provider partners. And use it for your own benefit.

With the growing need for preferred provider networks, how do hospitals manage potentially hundreds of skilled nursing facilities and track length of stay and performance and benchmarking across diagnoses? How do SNFs and other post-acute providers know how they stack up against their peers? Being able to see and share benchmark information about providers is helpful not only for health systems, but for post-acute provider facilities as well. Working together and creating synergy around communication and information sharing is the key to coordinating care – that is what helps meet the needs of the patients.

Care transitions are the riskiest part of risk-based programs.

At Mercy Health, care transition coordinators track patients for 90 days post-acute episode, regardless of where the patient goes post-discharge. It is an onerous process and this is where the opportunity for misses takes place – during the care transition – especially when the patient goes home.

Knowing when patients actually leave a facility – not the estimated date, but in real time – has helped Mercy Health keep track of patients and make sure they’re getting the care they need. This is particularly true on weekends and holidays – times when staffing levels are lower, but when patients and families prefer to be discharged. Every real-time alert of a patient discharge is a success story for Mercy Health.Getting real-time notifications and coordinating around patient care, whether that’s upstream or downstream is key to success in risk- and value-based programs. But with engaged providers, teams that work together, and the right data and information, it can be made easier.

Want to know more about how Mercy Health uses CarePort Connect? Read the Mercy Health Case Study.