Care coordination is critical to the success of population health efforts as it brings all of the moving parts of healthcare together on the same track. Care Managers at Northwell Health, New York State’s largest healthcare provider and private employer, with 21 hospitals and more than 550 outpatient facilities, are constantly in motion, tasked with digging into EHRs, compiling data, while also talking to patients and coordinating discharges. Thus, coordination is key.

“We use a homegrown care platform that was created by our IT department,” said Jennifer Laffey, supervisor, nurse practitioner, at Northwell Health Solutions. “The care tool pulls a daily list of patients who have qualifying insurance for our transitional program, and then looks at surgical diagnoses and creates a list. Every day we look at the list and determine if these patients are eligible or not. And based on that list we enroll them in the transitional program.”

Once patients are enrolled, Laffey describes the situation as akin to equipping them with a LoJack, the device planted on cars that tracks them in case of theft. 

 Learn more at the Pop Health Forum in Boston, April 3-4, 2017. Register here.​

“When they leave the hospital we get a real-time message of discharge, if they are admitted to another facility we get another notification with all of their information and presenting symptoms – we always know where they are,” she explained. “When we are in the hospital, this platform is our documentation tool for all of our engagements and interactions with the patients. We do medication reconciliation where things are pulled over from the inpatient side so we can compare pre-op medications, inter-op medications, and so on, to make sure we are not missing anything.”

The tool also allows caregivers to indicate information for other team members; and it pulls parts of the medical record, such as history and physicals, vital signs, and radiology studies, to offer caregivers a snapshot of the patient without needing the full chart from the hospital.

“We have all that information going on so we know these patients before we even see them,” Laffey said. “When we go in we are ready to engage them knowing their history, knowing we have all the tools we need to care for the patient. And this is very powerful in the outpatient setting, we are in our cars pretty much all day, we go to the patients in their homes or rehab settings, so having all that information at our fingertips is extremely beneficial and allows for more effective delivery of care.”

Care coordination is not an easy task, and in the case of Northwell Health, IT comes to the rescue.

“I was an inpatient provider for 13 years and you think you do a great job of sending someone home,” Laffey said. “But medications are lost, things are not reconciled, you do a referral for home care and you think home care is set up but home care never got the referral. All of these little things fall apart, but now we are discovering that within the first 24 hours. The people knowing what is happening on the inside and knowing what should happen on the outside, we are the glue that is holding everything together.”

If home care does not contact a patient, the platform helps staff identify that fact to contact home care to make sure the task gets performed, for example.

“It is taking things away from the patient and we are handling it, so it gives the patient peace of mind,” Laffey said. “Overall, we make sure that patients are safe at home.”

Laffey share insights from Northwell’s experience at the HIMSS and Healthcare IT News Pop Health Forum, April 3-4, 2017, at the Westin Copley Place in Boston, Massachusetts, during a session entitled “The Go-Cam View: Under the Hood of Population Health Management.”

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