Centegra Health System opted to participate in CMS' Bundled Payments for Care Improvement initiative. But at first, it wasn't sure how it was going to track, chart and monitor a patient's progress throughout a full 90-day episode of care.

None of Centegra's existing systems allowed it to chart pre-hospitalization or post-hospitalization, and it had no common platform for the various post-acute partners to be active participants in the care, with the exception of manual tracking, phone calls, faxing and so forth. All options were antiquated and time-consuming and fraught with missed opportunities.

So the health system turned to PreparedHealth's enTouch technology, a mobile communications platform for providers designed to reduce time and waste involved in transitioning patients from one facility to another and increase visibility for all caregivers involved with a patient's care. It has been using the platform for 18 months and now is rolling it out to all hospital discharges. 

[Also: Next-gen clinical communication: Real-time location, context-aware and mobile]

There are a variety of vendors of clinical communications technology with platforms on the market today. These vendors include Everbridge, IBM, Mobile Heartbeat, PatientSafe Solutions, Voalte and Zipit Wireless.

"The web-based system and app allow for communication and alerts to various partners in a patient's extended care team. Think of a HIPAA-compliant Facebook," said Astrid Larsen, director of care coordination at Centegra Health System. "We have extended its use to the discharge planners and designated nurses at our skilled nursing facility and home health care partners."

The fact that Centegra case managers are now able to know in real time any changes in the condition of their patients provides a proactive rather than reactive approach to intervention.

"For example, while we do not expect our case managers to work 24/7, they receive real-time alerts," Larsen said. "In one case, a patient was starting to have a decline in a post-acute facility. It was a Sunday night and the platform sent an alert that the patient was going to be seeing their primary care physician first thing in the morning. No one called the case manager but she was able to see an alert come through on her mobile app."

This notification did not interrupt the case manager's weekend but did allow for her to plan her morning the next day. She proactively met the patient at his appointment and helped problem-solve to avoid a readmission.

"Our referral process is cumbersome and time-consuming," said Larsen. "We make a phone call to a post-acute provider. The post-acute provider then has the responsibility to access our EHR to pull the pertinent information to determine whether or not they can accept the patient. The post-acute provider then calls the case manager back to discuss and ask any questions. They also often have to ask for additional information that the case manager then has to locate, print and fax."

In the new process, the case manager places a referral request through the platform, the post-acute care provider has all pertinent information via the platform – the data feed to the platform from the EHR – and responds to the case manager with an acceptance or not. Any additional questions can also be placed through the platform, if needed. No need to make additional calls, navigate an EHR, print and fax information, or leave messages for a callback.

"We track the percent of patients the case management team is involved with," said Larsen. "Our goal is always 100 percent, but this is not feasible with the number of case managers and the responsibilities their roles entail along with providing quality, patient-centered care, which takes time, kindness and genuine caring with the patients."

Centegra puts a strong focus on the patient first and the bulk of staff time should be spent in conversations with patients and families, she added, explaining that eliminating inefficiencies with the tedious tasks case management faces is paramount to this goal.

"Two years ago we averaged a 65 percent patients seen rate," she said. "Last month we hit 91 percent, and that was with a reduced number of FTEs."

For 2016, annually the organization had a 42 percent congestive heart failure readmission rate over a 90-day period; for 2017, it did better and dropped to 35 percent congestive heart failure readmissions over a 90-day period, said Heather Brown, BPCI congestive heart failure case manager. Currently, the organization is on track at about 30 percent congestive heart failure readmissions for 2018, she added.

"For congestive heart failure patients, we are making great strides with preventing readmissions from a home health standpoint, especially with our three top providers and their leadership teams that are so invested in our patient population and our program," she said. "They have worked really well with us keeping us in the loop of what is going on with the congestive heart failure patients for symptom management and education, communication with physicians and other patient caregivers."

The biggest success story of the organization's joint bundle is post-acute care utilization – patients going to certain levels of care and then how long they are there, said David Liss, BPCI total joint case manager. Collaboration through communication is the needle on which the platform has directly had an impact, which is reflected in the length of stay at post-acute care centers.

The percentage of patients going to a skilled nursing facility in 2016 was 54 percent; in 2018 to date, it is 20 percent. The average length of stay at a skilled nursing facility in 2016 was 12.6 days; in 2018 to date, it is 8.0 days. The percentage of patients going to home health in 2016 was 95 percent; in 2018 to date, it is 72 percent.

“The increase in efficiencies allows us to save money by providing better value to our patients," Larsen said. 

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com