IMPROVING TRANSITIONS OF CARE…ONE MEMBER AT A TIME

Successful transitions from one care setting to the next are a delicate balance of communication, coordination, and timing. When post-acute care is part of the journey, technology solutions and network management services combine to bridge the gap between payers, providers, and members. This collaborative effort sets the stage for a better member experience and better clinical outcomes.

Technology solutions like WellSky CarePort Guide and WellSky CarePort Connect have been instrumental in enhancing transitions of care across the continuum. Helion has been pivotal in leading CarePort operations across the health plan, Allegheny Health Network, and the post-acute provider network. Helion partners with network providers to develop and implement the appropriate use cases within CarePort and facilitates the integration of post-acute providers – all with the goal of improving transitions of care for the members served.

From a payer and provider perspective, CarePort Connect delivers end-to-end visibility from acute to post-acute to community, fostering seamless care coordination and improved outcomes. CarePort Guide is a robust tool that supports patients and families in the decision-making process of selecting a preferred facility for care, resulting in greater member satisfaction and reduced discharge delays.   

Selecting an appropriate post-acute provider can be an arduous process. There are many factors to consider when it comes to choosing a facility, including regulatory obligations. CarePort Guide supports the Centers for Medicare and Medicaid Services (CMS) Freedom of Choice requirement and emphasizes provider quality and patient choice. The interactive application is a provider directory that uses a dynamic search engine which enables the case management staff to curate a list of post-acute providers based on the member’s clinical needs, payer, location preferences, quality scores and other filters. Search results are displayed much like popular online hotel booking applications, featuring photos and video tours. The discharge planners can share the list with patients and their families so that they can make informed and confident decisions about the facility they prefer before the transition plan is finalized.

Providers within the health plan’s network are responsible for updating their CarePort Guide profile on a frequent basis to ensure the most accurate information is reflected. While some information within the profile, such as bed availability, COVID status, and clinical capabilities is maintained by the providers, other information is pulled in automatically from external data sources, such as CMS and Helion quality ratings. These quality ratings can often be the deciding factor when families are having a difficult time choosing a facility for their loved one’s care.

The CMS quality rating supports the Freedom of Choice regulation, which governs what information is shared with patients and families, including quality ratings for providers. Another quality indicator included in the facility profile is the Helion quintile ranking. This score is derived from metrics such as readmission rate, PCP/Specialist follow-up, and timely initiation of care, among others. Helion’s network performance management team meets regularly with network post-acute providers to review their dashboard (aka scorecard). The scorecard is an objective outcomes reporting mechanism which can help identify opportunities for performance improvement. Working collaboratively with the facility/agency, the network performance manager can share best practices for improving communication and care delivery across the continuum, which can also result in a better quality score.

Since 2019, Allegheny Health Network has leveraged CarePort Connect to optimize transitional care management within primary care. Practices have visibility into the member’s journey, including real-time alerts upon admission, transfer, and discharge from providers across the care continuum. Having more timely information enables providers to complete the CMS Transitional Care Management requirements, including following up with members upon discharge from an inpatient setting, bridging the transition to home. CarePort Connect serves as the singular location where transition of care notifications can be found.

“Being able to see patient discharges from outside of our own network has been a game changer,” says Dr. James Solava, a physician with the Allegheny Health Network. “In the past we would have to rely on the outside hospital calling or the patient calling our office for follow-up. Now with this tool, we can easily make our TOC call within two days and get the patient into the office within seven days.”

In addition to the traditional use of CarePort Connect for the use of TCM, Allegheny Health Network and the health plan have identified creative ways to leverage the application to support care coordination efforts and benefits coordination. For example, one use case is centered on referring eligible members for the in-home supplemental benefits program. Supplemental benefits include non-skilled services such as hands-on assistance with activities of daily living (i.e., toileting, dressing, bathing, etc.) and instrumental activities of daily living, such as laundry, preparing meals, managing chores and cleaning.

Providers can utilize the “Comments” feature within CarePort Connect to coordinate member conversations and the referral process for eligible members. When preparing a member for discharge to home, their non-medical needs are just as critical as their clinical needs. Ensuring the member will have the proper support services at home can facilitate better outcomes and reduce the risk of adverse complications and/or readmissions.

Helion recently conducted a survey to gather provider feedback on CarePort Connect. Nearly all 126 end-users who responded to the survey access CarePort Connect on a daily basis to monitor member hospitalization and discharge information. With an average satisfaction score of 4.23 out of 5, respondents find the application “easy” to use and acknowledged that their jobs would be “more difficult” without the features that CarePort Connect offers.

“Conducting this survey is just one mechanism we use to gather end-user input into our continuous improvement efforts,” said Stephanie Petitta, an associate strategy partner at Helion. “We use this feedback to partner with the vendor on product enhancements that enable more efficient workflows for the staff and ultimately improve the continuity of care for patients.”

From an end-user perspective, CarePort Connect has significantly improved the workflow for care coordinators and discharge planners with its automated real-time alerts and centralized hub of patient information. CarePort Guide “gives you an avenue for a more immediate response rather than taking time to call and outreach to each individual patient/facility,” one end-user shared. “All of the information I need is in one place.” Another end-user pointed out the importance of having insight into the patient journey when coordinating care. “Not knowing about a patient’s hospitalizations until after the fact could delay care needed when a patient first comes home or transitions to a SNF or rehab.”

Dr. Solava has incorporated CarePort Connect into the daily workflow of his primary care office and could not agree more with how the software has enhanced care continuity. “Being able to see real-time patient discharge information has been critical in providing patients with post-discharge services, resources, and primary care appointments which ultimately enhance patient outcomes and reduce readmissions. WellSky CarePort solutions have truly empowered our teams and allowed us to revolutionize patient care post-discharge.”

Robust search results at the push of a button. Comprehensive end-to-end visibility in one spot. Network management expertise to drive better quality. Collaborative communication between payers, providers, and members. A future where discharge planning and transitions of care don’t have to be broken. With technology like WellSky CarePort solutions and the support of Helion’s network performance management team, it IS possible to transform health care delivery across the continuum, improve the member experience, and achieve better outcomes.