Prior to implementing case and referral management technology, St. Luke's University Health Network was struggling with standardizing how it effectively and efficiently managed post-acute referrals across its 11 campuses in several counties.

THE PROBLEM

Without a centralized platform, each campus followed slightly different workflows, leading to a more fragmented approach that often resulted in additional delays in patient discharges. The inconsistency in how case managers handled referrals impacted the ability to efficiently allocate beds, contributing to unnecessary strain on inpatient resources, especially during peak periods.

A key issue was the lack of a streamlined, integrated system for filtering post-acute care providers based on patient-specific needs, particularly insurance and clinical criteria. Case managers often had to gather this information manually, relying on printed lists or outdated spreadsheets.

The process was cumbersome and prone to delays, sometimes resulting in back-and-forth as patients could get referred to facilities that lacked the necessary services needed or perhaps didn't actually have the space available at the time needed.

"This not only frustrated patients and their families but also led to additional administrative burdens as case managers had to navigate re-referrals or follow up with alternate providers," said Joanna Lucas, RN, vice president, care management, at St. Luke's University Health Network. "Our previous workflow was clunky. We didn't always know what the insurance companies needed, and we had to go back and forth far too often to get it right."

Beyond the referral and filtering issues, the reporting aspect also was a major pain point. The team had limited access to real-time, actionable data, making it nearly impossible to track key metrics, such as post-acute care provider response times or referral acceptance rates. Without these insights, staff could not effectively assess the performance of post-acute care partners, and the lack of accountability hindered staff from fostering quality improvements.

The lack of automated processes compounded inefficiencies, forcing case managers to perform redundant steps – such as printing, scanning and re-entering data into disparate systems. For instance, documents from the Epic EHR often would need to be printed out and then manually scanned into the legacy referral platform, an antiquated process that was both time-consuming and prone to errors.

The operational inefficiencies extended to the ability to manage compliance with regulatory requirements. Key forms like the Important Message from Medicare (IMM) and Medicare Outpatient Observation Notice (MOON), essential for meeting CMS requirements, were handled through time-consuming, manual steps.

"Without automated workflows, these forms had to be physically signed and scanned into our systems, adding extra steps to an already overloaded workflow and creating opportunities for human error," Lucas explained. "The manual process of tracking form compliance also complicated audits, as it required us to sift through scattered documents and spreadsheets to prove compliance with patient notifications and choices.

"So, our workflow was not only inefficient but placed unnecessary strain on case managers, compromised patient satisfaction, and hindered our ability to manage post-acute care transitions effectively," she continued. "These cumulative issues highlighted a need for a system that could unify, automate and provide transparent reporting across our network."

PROPOSAL

St. Luke's University Health Network had been using a referral platform but included case and referral management technology vendor Aidin in a detailed review on the health system's journey to find a more robust system to manage various care management workflows in one place. Ultimately, the health system was looking for standardization of processes, the ability to filter specific clinical and insurance information, and simpler yet more robust reporting.

"Aidin's technology presented St. Luke's with a structured and scalable case management platform that addressed several of our core challenges," Lucas noted. "At its core, the proposal centered on process standardization, bi-directional Epic integration, and streamlined data access to enhance our post-acute care referral workflows.

"The platform promised to unify our case management process by creating a standardized 'blanket referral' model, which allowed us to efficiently refer patients to a network of post-acute care providers based on their insurance and clinical needs," she added. "This shift enabled case managers to expedite the referral process, ensuring patients were matched with appropriate, quality care providers from the outset."

Additionally, the platform offered a reporting feature that delivered real-time insights into metrics such as referral acceptance rates, response times and discharge status, enabling St. Luke's to monitor and improve post-acute care provider accountability. By embedding transparency into the referral workflows, the vendor showed how it would help St. Luke's transition from a manually intensive system to a data-driven, automated process.

"This visibility was particularly valuable for making continuous process improvements, as it would allow us to measure time between key steps, such as time from admission to referral and from referral acceptance to discharge," Lucas said.

"The bi-directional Epic integration was another critical component of the vendor's proposal, designed to minimize redundancy by syncing data directly with our existing Epic HER," she continued. "This integration streamlined document sharing, allowing case managers to easily access and transmit patient information without redundant entry or the risk of error, which was a limitation of our previous system."

Aidin's customer support team helped solidify the proposal by promising support throughout the transition, ensuring a smooth rollout, she added.

MEETING THE CHALLENGE

At St. Luke's, Aidin was initially rolled out to the inpatient case management teams in the first phase and later to outpatient services. Case managers, including RNs and social workers, were the primary users, using the platform to streamline post-acute care referrals across all 11 campuses.

The Epic integration allowed for bi-directional data transfer, eliminating the need for manual data entry and making patient information readily available within the same system. This integration, Lucas said, was transformative – instead of printing and scanning documents as staff did previously, case managers could now pull data directly from Epic into Aidin and vice versa.

"One of the standout features of the new system was the ability to generate and track referral timelines," Lucas explained. "Case managers used this feature to monitor the entire referral process – from admission to discharge – ensuring timely follow-up and minimizing delays.

"Aidin's streamlining of the referral process was particularly impactful, allowing case managers to provide patients with a vetted list of post-acute care providers based on real-time availability, insurance compatibility and clinical criteria," she continued. "This feature not only expedited the discharge process but also allowed patients to make informed choices, improving patient satisfaction and ensuring quality post-acute transitions."

The platform also allows the post-acute provider to set up their own profiles so on the inpatient side staff can show patients what the post-acute provider can offer.

Another aspect of the technology that St. Luke's leveraged was the IMM/MOON automation. The IMM/MOON forms, which previously required labor-intensive handling, were automated through the platform's integration with Epic.

"Case managers could now have patients sign discharge paperwork directly on an iPad, reducing administrative load and compliance risks associated with manual processes," Lucas said. "The vendor's robust support and collaborative approach with post-acute care providers were additional factors that enabled St. Luke's to make a smooth transition to the platform.

"The vendor's team provided consistent check-ins, handholding for less tech-savvy staff, and support for our post-acute care providers, ensuring everyone was equipped to navigate the new system," she added.

RESULTS

With the new technology, St. Luke's saw a reduction in length of stay.

"St. Luke's has achieved measurable success across several key performance metrics," Lucas reported. "We have reduced length of stay for those patients going to post-acute facilities by 0.3 days. This decrease translates into significant bed availability and improved patient throughput.

"It has enabled us to open an additional 10 to 14 beds per day across the network, alleviating some emergency room overcrowding and enhancing our capacity to serve incoming patients," she continued. "The biggest success is standardizing the referral process using what we refer to as 'blanket referrals,' not sending to one post-acute provider at a time."

This allows post-acute choices by patients to be real choices and not choices for facilities that either aren't contracted with their insurance or for which there is no bed, or they can't provide the clinical services needed.

St. Luke's also saw improved post-acute care reporting and accountability throughout the process. Aidin's reporting capabilities provided transparency into post-acute care provider metrics, such as response times and acceptance rates. These metrics allowed St. Luke's to identify and partner with high-performing providers, ensuring patients received high-quality care while encouraging continuous improvement among its post-acute care partners.

"In addition, we have been able to track metrics by post-acute provider and give them their data so they can improve their referral acceptance rate and other metrics," Lucas noted.

ADVICE FOR OTHERS

"For other health systems considering similar case and referral management technology, be prepared to invest time and resources in change management," Lucas advised. "Introducing a new platform is a substantial shift for teams accustomed to legacy systems, and helping staff understand the benefits and why behind the transition is critical.

"We found that daily, weekly and monthly check-ins with staff and continuous support from our tech vendor were essential in overcoming the learning curve," she continued. "Providing hands-on support, especially for less tech-savvy team members, will ease the transition and help staff feel confident with the new processes."

It's also essential to ensure the technology integrates seamlessly with an existing EHR to avoid redundant data entry and maintain a streamlined workflow, she added. Integration not only improves data accuracy but also simplifies access to critical information, as St. Luke's experienced with bi-directional integration with Epic.

"Finally, proactively engaging with any stakeholders, including external stakeholders, is key," Lucas said. "For us, post-acute care providers are an important part of the process and communicating the benefits of this technology was crucial.

"The post-acute care providers are integral to the discharge process, and building strong, transparent partnerships with them will optimize outcomes and create a collaborative ecosystem that supports efficient, patient-centered care," she concluded.

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