Improving Coordinated Care During COVID-19 and Beyond

Improving Coordinated Care During COVID-19 and Beyond

This article originally appeared on Population Health Alliance's website.


Meeting the healthcare needs of patients requires multiple organizations, people and resources throughout the patient journey. As the patient moves through the system, simple, accessible and precise communication among care teams has the power to improve quality patient care. 

Healthcare navigation for providers and patients, however, has always been a barrier to potential sophisticated population health management interventions. The pandemic forced providers to adopt technology quicker and revealed there are ways to adopt technology and support clinicians  in the business of healthcare. In the week ending April 18, 2020, almost 1.3 million beneficiaries of Medicare or Medicaid received telehealth services compared to just 11,000 in the week ending March 7, 2020, according to current claims data — an increase of more than 11,718% in just a month and a half.

Historically, providers and patients slowly and reluctantly have adopted technology and telehealth. Some of the barriers to use include reimbursement criteria, regulations, cost and concern over the experience. During this national emergency, special exceptions are underway related to both privacy and reimbursement. Widespread use during an exceptional time may lead to ongoing adoption when life returns to normal - whatever that might look like.


Coordinating Care for Acute Care Patients 


Telehealth works for non-acute scenarios and provides follow-up opportunities once acute patients return home. Yet 26.3% of patients discharged from hospitals require institutional post-acute care, including skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). With the pandemic, it is estimated that approximately 24 million Americans could require hospitalization and/or intensive care for more than six months due to the pandemic. Estimates project at least 700,000 patients may require inpatient short-stay rehabilitative care and 10 million more may need outpatient rehabilitative services.

The journey to better outcomes requires optimal communication amongst hospitals, post-acute care facilities, patients and their families. Deaconess Health System, a premier provider of healthcare services in 26 counties across three states, has been at the forefront of innovation. For the third year in a row, they have been ranked by the CMS as a top 5 performing ACO in the country. 

Deaconess has seen success, in part, by using a software solution that enables their care teams to track and guide their patients as they transition to post-acute care. This has supported improved patient outcomes within their value-based care population health strategy. They began using the software prior to COVID-19, and it served as a vital platform to improve patient care coordination during the pandemic.

“Within all our community hospitals in the region, we can connect through the Olio software — especially those we either did not have a relationship with before or that we weren't able to connect with via EMR [electronic medical records],” says Shelly Evans, the former Manager of Post-Acute Services for Deaconess Health System. “We've been able to use Olio during the COVID pandemic for communication, and to look at COVID activity along with staffing resources because as a health system we want to help those facilities.”

Evans says the platform provides them a real-time snapshot of where that patient is in their journey, while tracking the length of stay along every level of care. “It ensures collaboration with those facilities to keep patients moving along the continuum in a very successful and timely manner,” Evans says.


Managing Escalations and Limiting Readmissions


Overseeing the discharge of hundreds of patients to post-acute facilities involves a great deal of complexity and economic burden, requiring active engagement at scale to make an impact. Managing care often includes manually tracking and monitoring patients through non-HIPAA compliant channels, and utilizing costly resources to coordinate communication between acute and post-acute providers.

“Our medical directors and nurse practitioners have been very receptive to the new platform, because they know exactly where our patients are, where they are in that journey, and provide the ability to communicate,” Evans says.


She shares that various electronic health record systems result in a gap in the care process as there is no conduit of communication between the hospital and the skilled nursing facilities when utilizing different systems. Deaconess uses Olio to communicate with the facility staff, ask questions, share patient records and monitor daily progress, resulting in the ability to track and successfully manage patients. 


“You can send a note back and forth to the staff of another facility and talk directly with nurses, all HIPAA protected,” says Jaime Redman, Lead Nurse Practitioner for the Accountable Care Organization program at Deaconess. “We can access care quickly through a provider without triggering a nuisance. For the provider, they have to manually escalate something and Olio is programmed in a way that's good for providers. There are not a lot of nuisance calls — only when they need you for something urgently.”


Supporting Coordinated Care in Real-Time


Healthcare workers’ efforts before, during and after the pandemic elevate them to hero status. Communication technology earns the title of supporting sidekick as providers embrace innovations to navigate new pandemic challenges. Telehealth and Olio, amongst other solutions, provide easy-to-use, real-time support for the best possible patient outcome and provider experiences. 

“Direct communication with the staff at the facilities is huge,” Redman adds. “We’re able to communicate with the nurse about what's going on without a phone conversation. A lot of times we're in the middle of meetings. We can communicate and not interrupt the meeting, place orders, go ahead and take care of this, and provide real-time solutions to real-time problems.”

Transcendent Healthcare of Owensville, LLC, a privately owned and operated Skilled Nursing Facility, receives referrals from Deaconess. The facility strives for innovative efforts when caring for lives. With the onset of COVID, communication with the hospital proved even more critical when providing patient updates, ensuring appropriate care, and managing patients in place.

Transcendent not only used Olio to get in touch more quickly with the hospital, but to schedule and conduct visits with the hospital through telehealth. “Olio’s program to improve communication in post-acute care measurably improved resident outcomes for us on a number of occasions and was pivotal in growing our relationship with Deaconess Care Integration,” says Tom O’Niones, Transcendent’s Owner and President.

“Our goal each day is to ensure resident health, safety and satisfaction,” O’Niones says. “As of 2020, and particularly during restrictions associated with the current pandemic, utilizing Olio as a tool enhanced our success plan. The speed by which we can access Deaconess providers to discuss crucial issues for our residents, with telehealth consults, is invaluable. We utilized Olio’s escalation feature multiple times with rapid response. We are certain this has improved coordination of care and likely helped save lives.”




Topics: Post-acute, Hospitals, Articles, ACOs, Population Health
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