With the number of primary care physicians referring patients to specialists steadily increasing, the size of the care team for a typical patient is growing. A recent Pew analysis found that healthcare is moving beyond just a primary care physician mode to a model that allows for more clinician collaboration, better enabling health systems to drive down costs and minimize errors.

But to succeed with the expansive team-based approach means effective collaboration and communication is key.

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Saint Francis Healthcare Partners has capitalized on using real-time data to improve care coordination and communication – and patient outcomes. The targeted population within its skilled nursing facilities has seen a more than 30 percent reduction in rehospitalization rates and improving the average length of stay by 27 percent.

Care coordination is an important component of population health. Some of the more prominent pop health companies, according to KLAS, include IBM Watson Health, Philips Wellcentive and HealthEC, right alongside EHR vendors including Allscripts, athenahealth, Cerner and Epic.

Saint Francis Healthcare Partners care managers use technology from vendor PatientPing to manage the length of stay and readmissions for a roster of patients.

“Saint Francis Healthcare Partners doesn’t need to enter information, as the real-time notifications are pushed to the care managers,” said Khadija Poitras-Rhea, executive director of care coordination and population health at Saint Francis Healthcare Partners.

Upon logging in, the information care managers need is on the platform. Saint Francis Healthcare Partners provides a patient attribution list into the system, as well as care program attributions and care instructions to its skilled nursing facilities network. This enables Saint Francis Healthcare Partners to collaborate with the skilled nursing facilities and receive real-time updates when patients experience a healthcare event.

“Saint Francis Healthcare Partners provides care instructions to the SNFs, which allows us to easily collaborate with one another on a shared patient. On our end, we receive pings, which allow us to know in real time when and where a patient is seeking care,” Poitras-Rhea explained. “We receive the ping, and can then choose to take the appropriate action based on the information we receive. Saint Francis Healthcare Partners care managers work with SNF partners to determine the proper level of care and expected length of stay, and to coordinate follow-up care.”

“Using the technology’s analytics to inform risk stratification, we can pinpoint users at risk for readmission and maintain a network advantage by keeping our ACO patients within the network," she said. "We can work directly with our SNF partners, in real time, to manage and reduce length of stay across our network, intervening as needed to adjust plans of care.”

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