Health System Gains Comprehensive View of Post-Acute Care
Learn how PointClickCare helped Ascension enhance collaboration and deliver high-quality care.
Time Savings:
Improved efficiency for case management with real-time visibility into updates for SNF patients
Better Patient Outcomes:
Real-time insight allows clinicians to catch medication errors, prevent missing meds, and reduce rehospitalizations and readmissions, as evidenced by 109 emergency department (ED) saves
PAC Management has become an integral part of our team. It's always there, never gets sick, and it helps us be proactive in patient care. The most valuable impact is having real-time insight into what's happening with our patients, allowing us to catch significant changes and collaborate with SNFs to prevent avoidable ED visits and readmissions. It's a feel-good moment knowing that we're making a real difference in patients' lives and supporting our SNF partners.
Samantha Caruso
Manager, Care Manager, Ascension Illinois
The Challenge
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Lack of visibility into real-time patient data created barriers to tracking patient status after discharge to post-acute care facilities and prevented proactive readmission avoidance after transfer to SNFs.
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Manual workflows, such as tracking patients using phone calls and spreadsheets, caused delays in communication during transitions, and obtaining patient information was time-consuming for both the hospital and the post-acute providers.
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Incomplete or manual information posed challenges to high-quality medication reconciliation efforts.
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Claims data lagged by up to nine months, making it a nonviable source for obtaining real-time information on patients.
The Solution
Ascension chose PointClickCare’s PAC Management for Health Systems to gain visibility into real-time data.
Ascension chose PointClickCare’s PAC Management for Health Systems to gain visibility into real-time data.
- Providers and care teams can track patients throughout their post-acute care journey and know when to intervene to prevent unnecessary readmissions.
- Partner SNFs are offered access to a Partner Toolkit for insight into shared performance metrics and enhanced collaboration with improved identification of patients.
- Reduce administrative burden for staff with integrated resident and family engagement products that support more efficient, transparent communications.
- Easily access and validate completed clinical assessments and med reconciliations.
The Outcome
Time Savings:
Improved efficiency for case management with real-time visibility into updates for SNF patients
Better Patient Outcomes:
Real-time insight allows clinicians to catch medication errors, prevent missing meds, and reduce rehospitalizations and readmissions, as evidenced by 109 emergency department (ED) saves.
PAC Management’s unparalleled post-acute data set offered Ascension meaningful benefits that help drive improved patient care and outcomes.
“Before PAC Management we had great relationships with our performance provider network, but we really were missing being proactive with readmissions,” explains Samantha Caruso, Manager, Care Manager at Ascension. “We always could review the readmission after the fact. We had weekly meetings where we would talk about the patients.”
Caruso adds, “PAC Management stood out above the rest. It gave us an inside view. While we can see the clinical documentation at a real-time pace, we’re able to give back to the skilled nursing facilities. If we notice a trend, we’ll reach out.”
This visibility contributed to tangible results: “One of the improvements that we have seen has been around our avoidable ED saves,” explains Caruso. “In 2024, we had 109 avoidable ED saves.”
Additionally, Ascension was able to address not only readmissions but also medication reconciliation, allowing them to catch errors or omissions proactively.
Their workflows have been streamline at the same time. “It’s saved us time and created efficiency and improved processes,” says Ann Marie Gaber Niemer, MS, BA, RN-BC, System Director Care Management Population Health at Ascension.
“We can do more with the same amount of people we have. Instead of doing less, we’re able to see more patients. When we lost it during a downtime, it was the first product the staff wanted back over every other solution we use. They love it. They can get everything they need at the tip of their fingers.”
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Hear from Ascension how PAC Management helped increase visibility into patient data and improve efficiency
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