Population Health Management Company Gains Post-Acute Visibility With PAC Management IQ
Learn how PointClickCare helps Tandigm Health deliver exceptional care by reducing readmissions, managing length of stay, and strengthening value-based outcomes.
16.7%
16.7% Reduction in overall readmissions
95%
> 95% Visibility into skilled nursing facility stays
PAC Management IQ gives us real-time visibility into skilled nursing: where our patients are, what’s happening, and who needs attention most. We went from seeing about 50% of our SNF stays to over 95%, which allows us to intervene earlier and support stronger transitions. Our nurses start each day using the AI-driven readmission risk score to prioritize outreach, and we’ve seen a 4% reduction in readmissions even at non-partner facilities. It’s expanded our reach, strengthened collaboration with SNFs, and delivered immediate value for our value-based care efforts.
Dana Pedrick
Vice President of Care Management, Tandigm Health
The Challenge
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Visibility gaps into post-acute patient stays created barriers to effective collaboration across the care continuum
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Claims data lagged months behind actual care delivery, leaving the team with no real-time visibility into SNF admissions. Readmission management, discharge planning, and follow-up were all reactive instead of proactive.
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Insight into patient status and risk was limited, impacting proactive intervention to improve outcomes like readmissions and length of stay
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Without complete data, understanding SNF and provider performance was difficult, interfering with the ability to build a robust post-acute and provider network
The Solution
Tandigm Health chose PointClickCare’s PAC Management IQ to support post-acute visibility and improve patient outcomes
Tandigm Health chose PointClickCare’s PAC Management IQ to support post-acute visibility and improve patient outcomes
- Real-time data shared across the care continuum establishes better coordination and collaboration with hospitals, Tandigm Health, and other providers in and out of the network.
- This visibility allows providers and care teams to track patients throughout their post-acute care journey, so they know when to intervene to prevent unnecessary readmissions.
- Tandigm Health also gained access to real-time performance metrics and CMS quality measures—including readmission rates, average length of stay, Star Ratings, health inspections, staffing, and rehospitalization rates—to track trends and collaborate effectively with post-acute care providers in the network.
The Outcome
16.7%
16.7% Reduction in overall readmissions
95%
> 95% Visibility into skilled nursing facility stays
By leveraging PAC Management IQ for AI-driven risk prioritization and to gain real-time visibility into post-acute transitions, Tandigm Health was able to substantially improve their value-based care outcomes.
Nicole Massey, Manager of Care Navigation at Tandigm Health, notes, “It was very hard to identify our value-based customers while they were in the skilled nursing facility and at discharge, when they’re at their most fragile state. By working with PointClickCare, we now are able to identify them immediately on admission and we know the minute they walk out the door, which is a huge advantage to helping prevent that readmission.”
By gaining comprehensive insights across the post-acute patient journey, Tandigm expanded their network visibility to more than 95% of SNFs, significantly extending their operational reach and efficiency. They also discovered a 4% reduction in readmissions even at non-partner SNFs.
Case managers can now collaborate with more facilities, scaling their capabilities without adding more staff, as well as better identify patients at risk for poor outcomes, enabling timely, proactive interventions that prevent complications.
Additionally, Tandigm discovered they now have a better understanding of how facilities and providers within their network are performing within value-based care outcomes. Dana Pedrick, Vice President of Care Management, explains: “It’s hard to get provider-level data, and PointClickCare has opened that window for us. We can now access physician documentation and clearly understand patients’ length of stay and readmissions. We have also been having very productive conversations with providers in SNFs, which has enabled us to formally partner with provider groups there.”
Thanks to PAC Management IQ, Massey shares, “PointClickCare has really helped us deliver on our promise to provide optimal care at the right time.”
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