Increasing Collaboration and Reducing Readmissions with PAC Network Management

This health system needed to improve and streamline its ability to monitor patients and coordinate care transitions effectively. With five case managers across the entire state, the team knew that they could not touch every facility and directly manage every patient.

The Goal

To meet the evolving needs of its providers and patients, the health system needed to:

• Shift from a discharge focus to a holistic care approach with an increased priority on post-acute collaboration.
• Create a team responsible for managing relationships and quality data exchange between hospitals and post-acute care providers.
• Improve and streamline the ability to monitor patients and coordinate post-acute transitions in a thoughtful, intelligent, and scalable way.

The Solution

The team turned to PointClickCare and its PAC Network Management solution which empowers clinicians to:

• Provide better care for patients by streamlining patient transitions and creating more efficient processes.
• Work with transitional nurse navigators to manage and shortlist patients who are at the highest risk and intervene when necessary.
• More efficiently manage higher patient volumes.
• Monitor risk trends and proactively influence care to operate one step ahead.

“What’s so attractive is the functionality PAC Network Management provides. Teams now have easy to access to data about each patient right in the clinical workflow at the skilled nursing facility, including medications they are taking, immunizations, lab, and treatment orders, and they know who is at high risk during transitions of care. We can get facilities — even the ones that we only send a handful of patients to each year — the info they need, when they need it, leading to better outcomes for our patients.”
– Care Management Leader