Leveraging PAC Management for Enhanced Care Collaboration

Health systems nationwide are facing significant capacity challenges, necessitating urgency and innovation in improving throughput and reducing readmissions. Key to addressing these concerns is better collaboration and communication between healthcare providers across the care spectrum and throughout the patient’s journey.

PointClickCare’s PAC Management solution answers this call, supporting efficient communication, seamless data sharing, and improved care plan adherence between hospitals and post-acute care settings.

The Urgent Need for Better Collaboration

The increase in capacity challenges across the care continuum is underpinned by other key factors that are not likely to be resolved overnight. These include the ongoing healthcare staffing shortages and an aging patient population with multiple chronic diseases and overarching social issues.

Building relationships, trust, and communication between healthcare providers in both acute and post-acute settings is an essential part of solving these challenges. As patients move through the care continuum, gaps in shared knowledge and vital patient information can impact transitions of care, decrease throughput, and lead to unnecessary readmissions.

In hospital emergency departments (EDs), throughput and capacity strain are leading to what the American College of Emergency Physicians (ACEP) has dubbed a “public health crisis,” with ED boarding times increasing. This contributes to an increase in patients who leave without being seen, a benchmark of concern to hospitals.

In skilled nursing facilities (SNFs), staffing shortages have led more than 60% of SNFs nationwide to limit admissions, further exacerbating the cycle. Patients who are successfully admitted to the SNF can then be at risk for hospital readmission either during their SNF stay or post-discharge from the SNF when health system providers lack clear visibility into patient status to intervene if needed after they leave the hospital.

The Right Tools Play a Vital Role in Collaboration

Effective utilization of technology can improve care collaboration and patient outcomes. Solutions like better analytic tools and remote monitoring tools can improve care management across the care spectrum and combat capacity and throughput challenges.

At the heart of this, the right care collaboration platform can uniquely link hospitals, accountable care organizations (ACOs) and post-acute providers to one centralized source of insights and data to drive more informed care decisions and greater patient visibility, and create better patient outcomes.

PointClickCare’s PAC Management solution allows health systems, ACOs, and other risk-bearing organizations to effectively monitor their post-acute patient population, identify high-risk patients, and prevent readmissions with real-time status updates.

Because readmissions further exacerbate the capacity crisis and negatively impact reimbursement for both health systems and SNFs, this timely collaboration is essential.

PAC Management Drives Large-Scale Improvements

PAC Management is successful in creating and improving care collaboration in part because of its scope. With PointClickCare, 2700 senior care facilities, 28,000 hospitals, and every major health plan can connect for collaboration, with a network encompassing 47 states.

This allows tools like PAC Management to provide deep key insights to physicians and case managers as patients move to post-acute care. Detailed chart-level patient data is shared across the care ecosystem directly from the hospital or skilled nursing EHR. Real-time hospital readmission risk scores help zero in on patients requiring attention, allowing for proactive care collaboration between acute and post-acute settings. Additionally, network scorecards streamline the manual process of collecting facility metrics and understanding real-time network-wide performance.

PAC Management in Massachusetts

In Massachusetts alone, 100% of the acute care hospitals are connected to the PointClickCare network, and about 70% of the skilled nursing facilities in the state are utilizing PointClickCare as their electronic health record.

The Massachusetts Health & Hospital Association (MHA) launched a monthly patient throughput survey in 2022 to help identify issues contributing to the capacity crisis. Patients in local hospitals were often waiting weeks, and sometimes months, for post-acute placement, and MHA identified patient readmission as a contributor to the ongoing crisis.

Additionally, when SNF admissions teams lack easy visibility into patient data, time and resources spent verifying and investigating information becomes a barrier to admission, decreasing throughput. In the event a patient does gain admission to a post-acute facility, the complete picture of their clinical status may have been obscured by these gaps in visibility, ultimately leading to an escalation of care and return to the hospital, starting the cycle over again and exacerbating capacity strain.

Providers who leverage PAC Management in Massachusetts have found they are able to more effectively transition patients to the right place at the right time by bridging communication gaps between the acute and post-acute space. With better visibility and communication, SNFs can ensure they are able to appropriately treat any comorbidities before the resident is admitted. They can speed up referrals, admit residents more quickly, and reduce data entry errors.

In the event of a transfer back to the hospital, ED clinicians receive the latest labs and medications within the EHR at the time of the patient’s admission, helping to triage patients faster. Providing the right information to case managers, as well as supporting services, when they need it, further ensures a successful and safe transition.

Join the Collaborative Network

To build trusting relationships between acute and post-acute providers, clear communication and visibility into patient information helps smooth transitions, avoid costly readmissions, and improve throughput. To learn more about the collaborative efforts in Massachusetts via PointClickCare, watch our new webinar hosted by MHA for insights from acute and post-acute organizations in the state.