Ohio’s Care Collaboration Conference: Uncovering Better Care Transitions

The need has never been greater for care collaboration, and the healthcare landscape in Ohio is no exception. PointClickCare recently hosted a Care Collaboration Conference for providers in Columbus, Ohio, providing a unique opportunity for attendees to understand challenges at the local level and come together to generate meaningful solutions.

One of the biggest challenges in Ohio is coordinating care for those who qualify for both Medicaid and Medicare coverage. In fact, the Ohio Department of Medicaid announced the development of the Enhanced MyCare program to better serve this vulnerable population.

To offer efficient care and better outcomes to a growing population of patients, the attendees represented at the Care Collaboration Conference shared best practices and resources available for patients and individuals, and ways to seamlessly share data and insights. This enhanced visibility and collaboration across the care continuum improves care transitions, care outcomes, and network performance.

Attendees using PointClickCare’s solutions spoke about the use of these tools as a crucial opportunity to better address the needs of these vulnerable and expanding patient populations.

Transitions of Care and Collaboration Opportunities

The Care Collaboration Conference and its attendees recognized that creating a connected and collaborative network is essential. With technology solutions like PAC Management, even a small regionally connected network can manage post-acute transitions more effectively. Without it, post-acute visibility is limited. For example, skilled nursing facilities are historically a high-cost care setting, yet gaining the information necessary to coordinate better care is elusive.

Some challenges noted by organizations who participated in the conference include:

• Accountable care organizations (ACOs) are often using delayed claims data to manage their network
• Discharge planners don’t always know which patients belong to a specific ACO and are not able to refer members to SNFs based on a clear strategy or network insights
• Primary care physician shortages can create care gaps post-discharge that organizations aren’t aware of without visibility into patient encounters
• Skilled nursing facilities (SNFs) are hesitant to allow ACOs to access their data due to security/HIPAA concerns
• Manual processes like calling for updates may return limited insights, resulting in missed opportunities to intervene

A problem overarching all these concerns is the number of providers involved in a single patient’s care, who may be unaware of the resources available between them without a clear line of collaboration. When providers can proactively respond to data, they can reach across the network to offer resources that might have otherwise remained untapped.

PAC Management Enhances Real-Time Visibility for Improved Outcomes

PointClickCare’s PAC Management empowers stakeholders with real-time data for seamless care transitions. It supports proper SNF admissions, sends alerts for patients at high risk of readmission, and helps monitor length of stay.

Access to performance metrics helps maintain a high-performing network, with visibility into key metrics like CMS quality ratings, while secure data sharing ensures HIPAA compliance.

New Opportunities for Improved Outcomes and Revenue

The Ohio expansion of dual Medicare and Medicaid enrollment represents a call to action — not just for organizations in Ohio, but across the country. As managed care evolves and Medicare enrollment accelerates, integrated care delivery models are essential to meet the needs of patients whose care must be coordinated across multiple networks.

In Ohio, PointClickCare covers 80% of post-acute facilities, providing real-time data that helps providers gain insights into patient encounters. With better network monitoring and visibility, care outcomes are improved and care is better coordinated, ensuring that patients do not fall through the cracks and cycle through multiple providers and encounters.

By responding quickly to patients at risk of readmission and supporting more effective care transitions, organizations also realize not only improved patient experience, but also cost savings. In an environment where value-based outcomes drive financial performance, this approach is critical to improving revenue. Without the ability to address patient needs in real time, there is both unnecessary healthcare spend and decreased reimbursement, with penalties levied against low-performing care providers.

This goes both ways — SNFs miss out on referrals and revenue as well because of difficulty in visualizing performance across the network.

Improving Network Performance by Closing Data Gaps

With the largest care collaboration network in the country, PointClickCare offers actionable insights at both the network and patient level. Information is no longer fragmented or obscured by delays.

Chris Phillips, National Director of Clinical Operations for Privia Health, noted “The biggest challenge for large, high-performing physician groups like ours is simply needing the speed and volume of ADTs to act quickly and meaningfully enough. We all know that TCMs (Transitions of Care Management metric) and FMCs (Follow-up after ED encounter with Multiple High Risk Conditions metric) move the ball the most on every utilization metric. Yet timing is everything. PointClickCare allows us to see every move of the patient in real-time between settings so we can seize the important moments in their journey.”

Beyond the Care Collaboration Conference

Ohio’s Care Collaboration Conference illustrates the shifting healthcare landscape and how organizations are adapting to stay on the leading edge of innovative solutions to solve challenges. Many are breaking down silos and collaborating with other health care organizations to improve the care experience of patients, not only within their individual buildings, institutions, or programs, but across the care continuum. Essential to this healthcare transformation is the use of real-time, actionable insights that otherwise prevent providers from working together in a meaningful way. PointClickCare, with its vast data network and collaborative solutions, is ready to serve those undertaking this transformation.