Digital Signals Help Providers Identify Vulnerable Patients
Imagine a patient – she’s an elderly woman who has several chronic conditions, lives alone, and has a high risk of falling. Picture her with an acute case of pneumonia, which forces her to go to the emergency department at Hospital A, which is close to her apartment. A few months later, she falls while on a visit to her daughter’s house located a town away. The patient is sent to a completely different emergency department at Hospital B where she is admitted for a fractured hip. When she is discharged from the hospital, she is then referred to a rehabilitation facility that is not affiliated with Hospitals A or B. To make matters more complex, her primary care provider has a practice affiliated with Hospital C and has no record that any of this has happened.
How can providers, especially those in the “health care dense” Boston area, help each other keep track of their vulnerable patients?
The Partners HealthCare system has started adopting a variety of event notification tools—including PatientPing, PreManage ED, and Mass HiWay—to keep track of patients inside the Partners system, as well as outside of it. In the past, staff at post-acute facilities like Skilled Nursing Facilities (SNFs) would need to manually enter patient information into the system. But, with new updates to these tools, along with a more robust, integrated electronic health record (EHR) system at Partners, alerts are now fed directly into the tools and out to patients’ providers in real time.
“There was always a vision that these would be useful tools and now with more robust enhancements we are seeing the value,” says Donna Rusinak, Senior Project Manager for Post-Acute Care at Massachusetts General Hospital.
A core objective of an Accountable Care Organization (ACO) like Partners HealthCare is to coordinate care for a specific population of patients—usually defined by their insurance coverage—within a unified system of doctors, hospitals, and other health care providers. Achieving seamless, coordinated care however, can be tricky if patients are receiving care outside of our Partners ACO. Not only can this lead to gaps in care, it can make it harder for clinicians within the ACO to identify and mitigate high-risk, high usage cases.
“Unfortunately, health care delivery is fragmented,” says Sree Chaguturu, MD, Partners Chief Population Health Officer. “However, by using these technologies, we can coordinate care better and respond quicker to our patient’s needs. We believe event notification technology is a back bone to a high functioning ACO.”
Event notification tools bridge the gaps between different health care systems and delivery sites. They serve as accessible, national communities of engaged providers who receive real-time clinical notifications whenever and wherever their patients receive care. These tools enable better communication across patients’ care teams to improve care quality, lower costs, and enable safer, more seamless care transitions.
“Knowing when our patients go from MGH to one of our Collaborative SNFs is pretty easy,” says Rusinak. “But now transitional care managers can also run reports and see if our patients have been sent to a SNF from outside our system. It really allows us to track those patients, reach out to them, and not unintentionally ignore them.”
She explains that event notification tools go both ways—they benefit our ACO but they also benefit the “other” health care system. For example, if a Beth Israel patient is admitted to a Partners hospital, they can be referred out to a Beth-Israel affiliated post-acute facility when they get discharged. Knowing where a patient regularly receives their care allows for a more thoughtful, coordinated transition back into their own health care system while opening a bed for one of our patients.
“It’s a win-win for everybody,” says Rusinak. “I’d encourage any health care system to consider these types of tools. The more people are on them the more powerful they become.”