Stitching together the patient narrative during post-acute transitions

Empowering Health Plan Care Managers During Post-Acute Care Transitions

Health plan care management teams play a crucial role in coordinating care for post-acute care (PAC) patients. Their efforts ensure seamless continuity of care, effective monitoring of critical patient events, and prompt interventions. However, maintaining this continuity presents challenges for health plan care managers, especially during patient transitions from acute care to skilled nursing facilities (SNFs) or PAC environments. These transitions often create a “data black hole” for health plan care managers. They frequently lack insights into a patient’s status until the patient shows up in another facility, such as a hospital emergency department. The lack of patient visibility during SNF transitions and stays can result in poor care coordination, often leading to preventable readmissions.

A Critical Opportunity for Enhanced Care Management

Despite advancements in interoperability, data sharing is often inconsistent and incomplete, making it difficult to obtain a comprehensive view of the patient. With data existing across various systems, including legacy systems and those with proprietary formats, data fragmentation hinders the integration of diverse data sources. Further, manual data collection and exchange workarounds are not conducive to coordinating care transitions or timely interventions. The data exchange problem is most evident when trying to coordinate high-risk member transitions between acute and post-acute providers.

Factors such as disjointed communication, limited resources, reliance on lagged claims data and time constraints can result in clinically limited and delayed patient data. This complicates the care manager’s ability to monitor patient conditions, spot high-risk individuals, identify critical care signals, and make informed decisions — especially after patients are admitted to skilled nursing settings.

For care managers, claims processing can be one of the first points of patient information, representing a substantial delay and making it difficult to track patient progress during post-acute stays. The absence of essential patient data at these junctures can hinder effective care coordination, delaying timely interventions and contributing to high readmission rates.

These statistics highlight a critical opportunity for enhanced collaboration between healthcare plans and PAC providers. Effective management of patient transitions and coordinated care is essential to reduce the likelihood of readmissions.

Meeting the High-Acuity Needs of PAC Patients

Complicating this issue is the increasing number of elderly patients in post-acute settings. The high-risk, high-acuity needs of the PAC population encompass chronic illness and comorbidities, increasing risks and costs, and demanding timely interventions. Without real-time data, care managers risk missing critical changes in a patient’s condition, which can negatively impact outcomes. In addition, incomplete information during PAC transitions may delay the administering of important medications or treatment plans.  Empowering care managers with better access to patient data can yield significant benefits for patients, providers, and healthcare plans.

Facilitating Payer-Provider Collaboration

Addressing this data gap calls for specialized tools that effectively connect health plans to PAC populations, ensuring the continuous flow of data and improved care coordination.

A connected healthcare ecosystem streamlines plan-provider communications between acute and post-acute settings by enabling data exchange, accessibility, and visibility. This enhanced data sharing empowers care management teams to monitor patient status throughout the care journey. With real-time visibility and collaboration between health plans and post-acute providers, care managers can ensure all care teams involved in a patient’s care are on the same page and working toward common objectives, reducing the risk of redundant or conflicting treatments. Access to clinical information facilitates medication reconciliation, real-time critical care monitoring, and early identification of potential issues that require intervention.

A connected network significantly enhances outcomes by:

• Streamlining care manager workflows with timely insights into SNF admissions, clinical assessments, medication reconciliations, and estimated discharge dates
• Empowering case managers to actively monitor patients during transitions and post-acute stays
• Identifying members at high or rising risk of readmission, facilitating timely interventions
• Allowing health plans to effectively monitor length of stay (LOS), anticipate discharges, and support patient follow-up
• Improving care quality while enhancing HEDIS and Stars ratings by reducing readmissions and LOS

“Our machine learning algorithm not only helps identify patients who may have a rising risk of rehospitalization but also the potential factors contributing to the increasing acuity. This enables those at the forefront of managing care to quickly prioritize patients who require attention and streamline clinical management.”

Shivani Goyal, Director, Product Management Post-Acute, PointClickCare

Customer Success: Improving Visibility and Collaboration During SNF Transitions

TriHealth was dealing with gaps in patient progress when they were discharged to a SNF. If a patient was discharged from a hospital outside the TriHealth system, they couldn’t see which SNF was caring for them. In addition, patient data didn’t flow with them, causing miscommunication and gaps in care and increasing readmission risk.
With PointClickCare’s PAC Management solution, TriHealth shined a light into the “data black holes” of SNF transitions and improved SNF relationships and continuous collaboration. They reduced hospital readmissions by 65%. 

Lori Baker, TriHealth Director of Population Health Care Management and Post-Acute Network stated:

What started as a focus on reducing medication errors transformed into a holistic view of healthcare for patients transitioning to a post-acute setting. We gained visibility into the patient’s progress and were able to be more proactive in supporting them across the continuum. We are notified when a patient is discharged to identify possible risks and help set them up for success while preventing negative outcomes like readmissions. This has improved patient outcomes and satisfaction.

Improve Visibility Into Patient Transitions With PAC Management

With PAC Management, care managers gain a complete picture of a member’s care status throughout the care continuum. PAC Management is built on real-time clinical insights, providing comprehensive visibility into admissions, discharges, status reports, LOS, therapy documentation, and individual patient charts. Additionally, the integration of readmission risk indicators and analysis from PointClickCare’s predictive return to hospital (pRTH) algorithm equips care managers to prioritize interventions effectively throughout the PAC stay. This strategy enhances patient care while also boosting partner CMS quality measures and overall performance, driving improvements across the network.