Facilitate Seamless Post-Acute Care Transitions and Improve Post-Discharge Outcomes
PointClickCare’s PAC Management improves post-acute transitions, patient outcomes, and skilled nursing performance through real-time data exchange and proactive collaboration.
Challenge
Lagging claims data and manual information retrieval processes are barriers to a timely patient status.
Solution
PAC Management provides real-time connectivity that drives efficiency. Transitional Care Managers can now see patients at higher risk for readmission and can look deeper into medications and vitals to determine if an intervention is needed.
Outcome
- Enhanced efficiency with transitional care workflows and patient tracking
- Enhanced care coordination between health system and SNFs
- Established a new post-acute care framework
Non-profit Catholic health system
19 states + DC
140 hospitals
35,000 providers
25,000 beds
Managing Medicare shared savings beneficiaries across 11 ACOs
The Challenge
Ascension is a leading non-profit Catholic health system committed to personalized and compassionate care across its locations nationwide, especially for those who are vulnerable or in need.
Like many health systems, they frequently faced challenges in tracking patient status after discharge to post-acute care facilities. Additionally, their reliance on manual processes, such as tracking patients using phone calls and spreadsheets, caused delays in communication during transitions. Furthermore, with claims data lagging by up to nine months, obtaining real-time information on patients was impossible.
Ascension’s care managers needed a solution that could provide real-time connectivity and drive efficiency. With limited insights, they experienced obstacles to clearly identifying which patients were at higher risk for readmission and determining whether an intervention was needed. Ascension recognized that better data could improve post-acute care transitions, promote better patient outcomes and help them collaborate more easily with skilled nursing facilities in their network.
The Solution
PointClickCare’s PAC Management is a powerful platform that connects hospitals and risk-bearing providers with post-acute partners to facilitate seamless transitions and improved post-discharge outcomes. It achieves this by offering providers and care teams the data they need to proactively monitor and care for patients under post-acute care.
For health systems like Ascension, better visibility and real-time data eliminates manual workflows and enhances collaboration, leading to reductions in avoidable readmissions and lengths of stay. The timely risk insights, powered by a proprietary machine learning model that predicts the risk of readmission in the next seven days, support more informed and responsive care for patients at higher risk of readmission.
These improvements in visibility across care networks also supports health systems with a better understanding of post-acute facility and partner performance. PAC Management simplifies and streamlines partner quality performance tracking and enables collaboration with skilled nursing partners so that improvements in quality of care are collaborative and meaningful and develop and maintain high network performance.
The Outcome
Ascension began implementation of PAC Management across 50-60 partner skilled nursing facilities, and immediately observed enhanced care coordination between the health system and the post-acute facilities. “What we have seen is a more collaborative process across our care teams,” states Kristine Bartley, AVP of Episodic and Alternative Payment Models at Ascension. “Where we usually had minimal handoffs and minimal engagement on transitions, now we are really collaborating more and talking through the workflows and the handoffs. We’ve developed an entire post-acute care management pathway that we did not have before.”
Additionally, Ascension found that PAC Management offered direct connectivity to their post-acute network and the capability to easily track patients. This led to improved efficiency and opportunities to achieve better outcomes. Before implementing PAC Management, Bartley notes that tracking patients throughout the care continuum was challenging. “Now, we can establish processes to track our patient population upon discharge, monitor their length of stay and vitals, assess rising readmission risks, and manage patients from discharge from the SNF all the way through to their return home and reintegration with their primary care provider.”
Learn More
If you’re interested in implementing PAC Management to help your organization achieve results like those experienced by Ascension, contact our team for more details.