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Improving continuity of care

Improving continuity of care

It’s common for patients with multiple chronic conditions to access different care settings and providers for health care services. If those clinicians all work for the same hospital system, they can typically see when their patient receives care from within the organization, regardless of whether it’s a trip to the emergency room, a specialist appointment or receiving post-acute care like nursing home services. That makes it easier to coordinate care and ensure a great patient experience.

However, what happens if someone experiences a medical emergency while traveling? Or what if a patient is sent to a nursing home or skilled nursing facility?

“Presently, there is no visibility of where the patient is receiving care,” said Hoa Cooper, vice president of Care Management for OSF HealthCare. “If our clinicians know what type of care our patient is receiving, we can ensure the seamless coordination of their care from the hospital to their recovery phase, improving their experience and quality of life.”

Performance Improvement, a part of OSF Innovation and OSF Care Management, saw this as an opportunity to bring in a new technology to solve this issue that health care systems share across the country. The two are testing Bamboo Health’s Pings, a platform that delivers real-time notifications whenever a patient experiences a care event. The goal is to manage complex and frail patient populations better.

Most at risk

To get ready for the trial, Performance Improvement and Care Management have been working with IT to build an Admit Discharge Transfer interface with the platform. This will provide patient information that will supplement their electronic medical record.

They’ve also been working with a core team to develop workflows and the strategy to roll out the technology. The next step is to incorporate 5000 people who are considered the most at-risk for hospitalization or emergency care.

“Using the Pings platform, we will get notified any time an at-risk patient ends up at a hospital, a nursing home or an emergency department within and outside of the Ministry,” said Cooper. With this information, Care Management can follow up with the patient or facility, see how patients are doing and determine whether they are receiving the best care possible.”

The benefit is two-fold. The first is to better manage where chronically ill patients go for treatment, ensuring a higher quality of care. The second is to improve the health of this population.

Measures for success

OSF will be testing the use of Bamboo Health’s Pings platform for 180 days.

“As part of this work, we will be looking at a variety of measures to conclude how well this technology works,” said Kaveri Armenta, a Performance Improvement specialist. “This includes determining whether we can increase the number of patients in our care management program, reduce hospital and emergency department admissions and readmissions, reduce skilled nursing facility length of stay, decrease costs and grow out of network visibility.”

Cooper says more than that, using this platform is an effort to do the right thing for OSF patients.

“Our Mission is about providing the best care and experience possible to the people we serve. We believe this technology is going to help us do that.”