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Your Health Improves Patient Follow-up Care By Over 90% With Pings™

The Challenge

In Georgia, 80% of hospitals face high rates of patient readmissions and can be penalized with lower Medicare reimbursements as a result. Georgia patients struggle to receive appropriate levels of care, while hospitals and provider groups struggle to reduce readmission rates and receive adequate funding.

As a primary care group with a specialty division serving patients across South Carolina and Georgia, Your Health Inc. (Your Health, formerly known as SC House Calls) needed more granular data at the regional and departmental levels to effectively manage their care teams and track hospital admissions and readmissions to improve patient outcomes. With varied attribution between patients and providers due to the wide-ranging groups that may help just one individual, it was critical to better manage care teams of dietitians, therapists, transitional care managers and more. Additionally, the team wanted to effectively integrate key data to overcome logistical difficulties and administrative burden. Your Health was looking for a partner that could offer actionable data to facilitate incentives for transitional care management (TCM) visits and provide insight into metrics that would support decision-making in their value-based care programs.

The Solution

Your Health partnered with Bamboo Health to streamline data integration, improve care transitions and foster greater accountability across teams. The organization uses Bamboo Health’s Pings solution to support workflows that enhance patient outcomes, optimize resource allocation and align with value-based care initiatives.

“Bamboo Health allowed us to find details that traditional reporting would miss. Not just find those data points, but to actually be able to act on follow-up with patients and know where other care events happening with views into specific regions and specific care settings.”

David Clements Executive Director of Value-Based Care at Your Health

The Impact

By integrating with Microsoft Power BI, Your Health
was able to:

  • Increase Accountability: Metrics for follow-ups within 48 hours and between 7-14 days were maintained above 90% compliance with payer requirements, a critical threshold for value-based contracts.
  • Improve Real-Time Data Integration: With greater visibility into patient data and metrics, Your Health was able to visualize key metrics, track trends, identify areas for improvement and make data-driven decisions.
  • Enhance Hospice and Home Health Management: Your Health used data insights to refine referral and follow-up workflows, ensuring patients received appropriate levels of care and reducing average length of stay.
  • Empower Transitional Care Professionals (TCPs): With real-time data, Transitional Care Professionals (TCPs) can monitor and support patients throughout their hospital stay and transition to post-acute care by filtering alerts and notifications specific to the facilities they serve, enabling TCPs to serve as patient advocates even at partner facilities. This is especially important for Your Health, where TCPs are embedded in both SNFs and hospitals.

Bamboo Health allows us to have visibility into various care settings because we’re not always the one who sends or signs the order for patient care given that often the hospital sends it or the specialist sends it. Before Bamboo, we didn’t know when organizations were sending orders until the home health agency came 60 days after requesting an order to be signed, and we realized we could’ve been helping a patient 60 days earlier.

David Clements Executive Director of Value-Based Care at Your Health

The Results

Through improved data transparency and
streamlined workflows, Your Health has been able to:

  • Improve follow-up measures by proactively managing care transitions and ensuring over 90% of patients receive follow-up care within 7-14 days
  • Develop a more efficient, data-driven approach to hospice and home health evaluations, which has increased Your Health’s monthly home health evaluations from approximately 300 to over 1,200 per month
  • Enhance TCPs’ impact as patient advocates, bridging communication gaps between patients and healthcare providers and allowing for more strategic planning and cost savings, including:

increase in home health revenue

decrease in hospice spend

decrease in home health spend

decrease in SNF spend

decrease in ED spend

reduction in cost to manage inpatient patients per month

How Home Health Organizations Can Leverage Increased Engagement

An inside look at Your Health’s Enhanced Workflow

1. When a patient appears at a skilled nursing facility or hospital, transitional care professionals (TCPs) are engaged to support coordination next steps.
2. TCPs access Bamboo Health data directly in their existing Microsoft Power BI platform to analyze and visualize data across different care groups.
3. TCPs set up the first five post-discharge appointments, coordinate with care managers and track progress all in the Pings workflow.
4. Using the patient roster tab, TCPs have visibility into all admitted and discharged patients for real-time monitoring.
5. TCPs can set up unique filters to track patients admitted to specific facilities or those they have visited with prior.
6. TCPs can also see the number of Pings vs the number of patients receiving a follow-up visit within 48 hours to better monitor and engage patients during follow-up.
7. To continue encouraging use of Pings for improved outcomes, Your Health offers incentives and a bonus structure for home health providers that help with follow-up after discharge.
1. When a patient appears at a skilled nursing facility or hospital, transitional care professionals (TCPs) are engaged to support coordination next steps.
2. TCPs access Bamboo Health data directly in their existing Microsoft Power BI platform to analyze and visualize data across different care groups.
3. TCPs set up the first five post-discharge appointments, coordinate with care managers and track progress all in the Pings workflow.
4. Using the patient roster tab, TCPs have visibility into all admitted and discharged patients for real-time monitoring.
5. TCPs can set up unique filters to track patients admitted to specific facilities or those they have visited with prior.
6. TCPs can also see the number of Pings vs the number of patients receiving a follow-up visit within 48 hours to better monitor and engage patients during follow-up.
7. To continue encouraging use of Pings for improved outcomes, Your Health offers incentives and a bonus structure for home health providers that help with follow-up after discharge.

About Your Health

Your Health, Inc. offers healthcare services that bring the convenience of a traditional doctor’s office visit directly to the comfort of the patient’s home. Patients have the flexibility to choose between in-person visits, at home, in a clinic, or wherever they reside. Your Health provides personalized care plans, medication management, the ordering of tests, labs, specialist referrals, follow-up appointments, remote patient monitoring and much more.

About Bamboo Health

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.

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KLAS Research: Improving Quality Metrics & Outcomes for Medicare Advantage Patients Through Real-Time Information With Humana and Privia Health

UChicago Medicine Improves Patient Outcomes While Reducing Costs With Rising Risk Solution

The Challenge

In Chicago, more than 65% of premature mortality is tied to social determinants of health (SDOH). From environmental factors (lead exposure) to low-income access challenges (lack of transportation and high rent), Chicagoans struggle to access the care they need during critical health moments.

The University of Chicago Medicine (UChicago), a not-for-profit academic health system formed in 1927, recognized the need to proactively address SDOH barriers after noticing stark gaps in care. To allocate resources for SDOH patients, UChicago first needed to gain a better view of which patients were at risk. UChicago collaborated with Bamboo Health to achieve this goal of expanding value-based care outcomes for vulnerable patients, including reducing costs through identifying potential high-utilizers of costly care.

Before implementing Bamboo Health’s Rising Risk solution, UChicago faced challenges in identifying and tracking patients at risk of becoming high utilizers of medical services, such as frequent emergency department (ED) visits amid a sea of SDOH barriers. The primary challenge was the need for a streamlined and automated process for monitoring rising and high-risk patients. Care coordinators at UChicago had to rely on custom filters within their patient management system or claims data, which is often 60 to 90 days lagged. This manual process often led to missing these rising or high-risk patients due to unavailable and/or obsolete data or lack of visibility into patients seen by an out-of-network primary care provider. As a result, some patients received care from costly healthcare settings like the ED.

The Solution

UChicago adopted Bamboo Health’s Rising Risk solution to enhance its patient identification and tracking process. Rising Risk, part of Bamboo Health’s Pings suite, offers multiple tailored solutions based on Pings admission, discharge and transfer (ADT) insights, providing real-time insights on patients at risk of high utilization of healthcare resources and eliminating the need for manual custom filters. With Rising Risk, care coordinators at UChicago can efficiently monitor patients, identify those needing care coordination and intervene in real time.

Doctor working with mobile phone and stethoscope and digital tablet laptop in modern office at hospital in morning light

“The availability of real-time data directly in our workflow helps eliminate a lot of extra work. It also allows us to catch patients while they’re currently in care, making it easier to build rapport to ensure follow-up and improved care quality.”

Kate Sullivan Project Manager at UChicago

The Results

Rising Risk Further Helps UChicago to Achieve:

  • Improved Patient Identification of At-Risk Patients: Rising Risk provides a condensed list of potential high-risk patients before they become high utilizers of the medical system. This makes it easier for UChicago to identify and monitor patients in real time.
  • Timely Intervention for Improved Outcomes: Real-time insights enable care coordinators to intervene while patients are still in the hospital or soon after their visit with the SMS contact-sharing feature, allowing the option to connect to follow-up care such as skilled nursing facilities.
  • Enhanced Patient Engagement: Patients are more likely to be involved when care coordinators can establish a timely relationship with them and connect them to the appropriate longitudinal care. UChicago’s recapture rate significantly increased after implementation, seeing how quick outreach made patients more willing to continue the momentum.
  • Effective Patient Tracking: Rising Risk ensures that patients are noticed, even when primary care providers are unavailable or out-of network, a traditionally laborious or complex process. With targeted post-discharge follow-up, patients have the opportunity to enroll in care management programs.
  • Advanced Analytics and Data Access: When UChicago adopted Rising Risk, it gained access to nationwide ADT data through the most powerful care coordination network in the U.S., allowing the organization to leverage real-time ADT data combined with predictive analytics and machine learning to identify and track patients throughout their care journeys.
  • Optimized Workflows: UChicago directly manages patient prioritization and post-discharge follow-up in its electronic health record. The simplified workflow allows for even greater efficiency during follow-up.
A female doctor with tablet talking to patient in bed in hospital MOBILE discharge summaries

The Impact

At the end of 2023, a patient (who we will refer to as John) had a chronic condition. When John experienced pain or needed support, he visited the ED. While the ED could support John in the short term, he was in desperate need of longitudinal care to manage his chronic condition after three ED visits in three months. Care coordinators at UChicago received an alert via Rising Risk that John appeared at the ED more frequently than other patients. This alert helped coordinators connect John to the care he needed, ultimately referring him to a skilled nursing facility and arranging follow-up appointments to support him with his chronic condition. With Rising Risk’s patient identification support, UChicago Medicine managed these additional appointments and brought him back into care with his primary doctor at UChicago post-discharge.

 

“It’s so helpful for us to see where patients are having external utilization troubles that typically we couldn’t catch. It’s amazing to pull people back into our network and connect them to the care they need.”
– Kate Sullivan, Project Manager at UChicago

 

In addition, UChicago uses Rising Risk to identify patients who may need support due to SDOH. Another patient (who we will refer to as Kelly) arrived at her primary care provider reporting physical health concerns. After the Rising Risk tool’s predictive analysis determined risk (based on data around hospital utilization, demographics, geographic location, diagnosis history and insurance), care coordinators received a Ping in the Rising Risk platform that Kelly had barriers to care that would prevent timely follow-up, including the need for transportation. UChicago’s care coordinators were able to arrange transportation to help Kelly get to and from her necessary medical appointments. As a result, Kelly could easily access her follow-up appointments and get the essential care that would have otherwise been postponed or avoided altogether. Numerous UChicago patients have been identified and brought into follow-up care under similar circumstances.

The implementation of Bamboo Health’s Rising Risk solution has significantly influenced UChicago Medicine’s care coordination efforts, including:

patients identified in the first year of implementation, who otherwise would’ve fallen through the cracks

patients referred to UChicago’s Ambulatory Care Coordination Team for follow-up

minutes on average saved in reviewing patients’ charts

average hours saved in chart reviews

How Rising Risk Works for UChicago Medicine

1 On UChicago’s Rising Risk platform, an alert appears that a patient of theirs arrived at an ED.
2 A referral is needed since this patient has visited the ED four times in the last two months.
3 The patient is enrolled in a care management program to address health needs.
4 UChicago receives relevant alerts about the patient to track progress and health system utilization.
5 The patient completes follow-up care, and UChicago is then notified to help close gaps in care for improved outcomes.
1 On UChicago’s Rising Risk platform, an alert appears that a patient of theirs arrived at an ED.
2 A referral is needed since this patient has visited the ED four times in the last two months.
3 The patient is enrolled in a care management program to address health needs.
4 UChicago receives relevant alerts about the patient to track progress and health system utilization.
5 The patient completes follow-up care, and UChicago is then notified to help close gaps in care for improved outcomes.

About the University of Chicago Medicine

University of Chicago Medicine (UChicago Medicine) is a not-for-profit academic health system formed in 1927. Based on the campus of the University of Chicago Medical Center in Hyde Park, and with hospitals, outpatient clinics and physician practices throughout Chicago and its suburbs, UChicago unites five organizations: Pritzker School of Medicine, Biological Sciences Division, Medical Center, Community Health and Hospital Division, and UChicago Medicine Physicians.

About Bamboo Health

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.

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WISHIN Improves Coordinated Care for Patients and Members With Real-Time Care Intelligence™

The Challenge

For organizations with a large geographical footprint, it can be a challenge to proactively manage patient outcomes and deliver timely and seamless care. The Wisconsin Statewide Health Information Network (WISHIN) is an independent not-for-profit organization dedicated to bringing the benefits of widespread, secure and interoperable health information technology throughout the state of Wisconsin. WISHIN’s network has nearly 2,200 sites of care, and includes physicians, clinics, hospitals, health systems, pharmacies, clinical laboratories and health plans located in Wisconsin.

WISHIN’s goal in working with Bamboo Health was to provide innovative interoperable solutions to its participants, enabling instant access to comprehensive and secure clinical data when it matters most. WISHIN identified the critical need for visibility into clinical encounters that occur beyond the four walls of a risk-taking system. Patients are mobile and oftentimes receive care outside of their networks, making it even more important to reduce information silos. WISHIN aimed to streamline data exchange for improved patient outcomes, aiming to reduce administrative burdens while decreasing the total cost of care.

The sooner our participants have visibility into an encounter happening, the better they can coordinate care with their patient or member and avoid scenarios that negatively impact cost or quality.

Steve Rottmann WISHIN COO

The Solution

Today, WISHIN’s partnership with Bamboo Health complements and extends WISHIN’s capabilities as a health information exchange (HIE). Bamboo Health’s Pings™ solution pushes real-time notifications through to providers and payers enabling them to respond quickly to patient care events. Bamboo Health’s solutions are a first step in a process that allows providers to begin their care-coordination workflows.

Real-time alerts were particularly appropriate for WISHIN’s Medicaid managed care organizations (MCO) participants, which needed visibility into emergency department (ED) and inpatient admissions and discharges. This was to help avoid unnecessary ED utilization and to help the MCOs better manage certain chronic conditions. In addition, this helps lower costs for the entire Medicaid program, producing notifications when needed most. WISHIN participants are also able to leverage real-time alerts and notifications for transitional care management (TCM) billing opportunities, which could serve as a growth and sustainability opportunity for their organizations.

Through the partnership, WISHIN participants have access to Bamboo Health’s nationwide care coordination network. This means that not only do WISHIN participants have access to timely and actionable insights within Wisconsin, but they’re also able to glean insights from other providers wherever their patients are in the country. If a participant’s patient experiences a care event in a Florida hospital connected to Bamboo, the care team in Wisconsin will receive a real-time alert.

In addition, the partnership particularly extends the reach of WISHIN’s network through post-acute and home care. By joining WISHIN’s and Bamboo Health’s networks, the two organizations provide value by creating engagement opportunities between many facets of the care continuum.

Bamboo Health’s integration with WISHIN is an open system and EHR-agnostic. This means that regardless of an organization’s size and the EHR platform it uses, an organization can receive relevant and timely information across the network.

Further, Bamboo Health and WISHIN’s partnership allows members to receive up-to-date clinical data through a single sign-on system. With Bamboo Health, when WISHIN’s participants receive real-time notifications, they can easily and seamlessly view additional clinical detail on the patient from WISHIN without signing on to WISHIN Pulse and searching for the patient.

Through the partnership, WISHIN participants also have an improved ability to connect with their members with up-to-date contact information at their fingertips. According to WISHIN, “Having all the clinical data in the world doesn’t help our clients if they can’t make contact with their patients.”

The two organizations champion actionable interoperability through secure real-time information exchange and alerts that improve care coordination throughout and beyond Wisconsin.

“We were aware that many of our members were interested in real-time event notifications and we were looking for the best option to meet that customer demand. We also wanted a partner that would be able to support a single sign-on, between their system and ours. That knock at the door that something potentially significant has happened with a patient or member often requires additional context, and that information needs to be in one place. That’s how our partnership with Bamboo Health started.”

Joe Kachelski WISHIN CEO

The Results

Since the WISHIN and Bamboo Health partnership was formed:

  • Roster-submitting organizations have seen a 22% decrease in emergency department (ED) to inpatient admission conversions since January of 2022, meaning that individuals are finding more appropriate treatment options rather than relying on the costly ED.
  • WISHIN has added 200+ post-acute facilities to its network, which strengthens and adds to the data all WISHIN participants have across Wisconsin.
  • WISHIN participants received 890,874 Pings in the past year from 1,075 unique facilities across 46 different states (including WI), meaning there have been more than 890,000 real-time alerts sent to an individual’s care team from the Pings platform. Overall, this improves the chances that patients are connected to the right care at the right time.
  • Within the last year, there was an average of 306 clicks per month in WISHIN Pulse from the SSO integration with the Bamboo Health platform. This means that a patient’s care team was able to find updated information about a patient in one system rather than navigating between platforms.
  • Since January 2022, more than $17 million in revenue potential has surfaced within the Pings platform for WISHIN participants that may bill for transitional care management (TCM).
  • 22%

    decrease ED to inpatient conversions

  • 200+

    added post-acute facilities

  • 75%

    of Wisconsin hospital discharges are visible by WISHIN

About WISHIN

WISHIN is Wisconsin’s state-designated entity for electronic health information exchange. It is an independent not-for-profit organization dedicated to bringing the benefits of widespread, secure, interoperable health information technology to patients and caregivers throughout Wisconsin. WISHIN is operating and maintaining a statewide health information network to connect physicians, clinics, hospitals, pharmacies, and clinical laboratories across Wisconsin. Our vision is to promote and improve the health of individuals and communities in Wisconsin through the development of information-sharing services that facilitate electronic delivery of the right health information at the right place and right time, to the right individuals. Visit wishin.org to learn more.

About Bamboo Health

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.

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Crisis Support Services of Nevada Streamlines Behavioral Healthcare Referrals With OpenBeds®

The Challenge

In 2020, Nevada ranked 51st in the nation overall for mental health, a ranking that indicates a high prevalence of mental illness, including substance use disorder (SUD) and low levels of access to mental healthcare.

Like other 988 Lifeline call centers nationwide, the Crisis Support Services of Nevada (CSSNV) grappled with the challenge of maintaining a roster of trained professionals to offer effective aid to increased frequency of callers. During pressing situations, CSSNV case managers would place callers on hold while they scoured the web for nearby behavioral health providers who offered the necessary services. After identifying a provider that accepted the caller’s insurance, the case manager would then link them with the caller. Unfortunately, CSSNV lacked an electronic method to monitor if callers followed through with the referred service. Those few referrals that were made often lacked crucial information, such as the challenges callers had obtaining food, transportation or housing that could be addressed by a case manager.

“We were doing it manually for every provider one by one,” explained Mele Eteuati, Case Management Coordinator for CSSNV. “That process was really tiring for our staff and not at all ideal.”

The absence of a cohesive referral platform that incorporates an extensive database of behavioral health provider organizations detailing their specialties and accepted insurances posed limitations to CSSNV staff, restricting them to information that could be found through internet searches or phone calls. Consequently, numerous behavioral health providers equipped to take referrals remained undiscovered by the CSSNV staff who catered to callers all over Nevada. Furthermore, managing and tracking the referrals was a convoluted process that relied entirely on manual work.

Female doctor explaining something to two male doctors

The Solution

Nevada’s Department of Health and Human Services (DHHS) made a strategic move to improve support for Nevadans who were experiencing behavioral health issues. Leveraging grant funding from the Centers for Disease Control and Prevention (CDC), DHHS initiated a statewide program, Nevada Health Connection, to encourage the use of the OpenBeds®️® platform from Bamboo Health. OpenBeds, a closed-loop referral system, connects individuals requiring assistance with mental health and substance use disorder treatment providers.

OpenBeds shows current and up-to-date information on available behavioral health treatment resources and provides an automated, standardized process for making and tracking referrals that speed access to care, streamlines collaboration and improves individual care outcomes. With OpenBeds, CSSNV staff can identify provider organizations in real-time that accept the patients’ insurance type, provide the required treatments and verify that services are located near the individual’s home. The platform also enables staff to send electronic referrals to three providers at once rather than the one-off manual approach.

“The ability of OpenBeds to capture the caller’s insurance status in the referral is especially valuable,” said Eteuati. “We deal with a vulnerable population, including people who have never used their insurance before, because they’re covered under a parent’s insurance or their parents were able to get them qualified for Medicaid, and they have never had real job opportunities. There are also elderly adults with Medicare and Nevada’s un-housed citizens. It’s been super hard to get this particular population into treatment. OpenBeds has allowed us to help facilitate them when no one else can.”

Moreover, because OpenBeds also captures social determinants of health within a referral, patients are “not just getting into treatment, whether for mental health or substance abuse, but they will actually get help finding a shelter they can go to, getting connected to low-cost or no-cost medical services or a food pantry,” said Eteuati.

“For us, OpenBeds is vital to getting people the behavioral healthcare and other services they need to thrive. We look forward to getting even more providers participating in the OpenBeds platform so we can deliver comprehensive service to every Nevadan who experiences a behavioral health crisis.”

Rachelle Pellissier Executive Director of CSSNV

The Results

OpenBeds catalyzed a shift in CSSNV’s referral process, which increased the probability of successfully linking individuals in crisis to critical support services like crisis stabilization, peer support, group homes, recovery support and withdrawal management. The adoption of the OpenBeds platform has greatly simplified the process for CSSNV case managers to guide callers to necessary behavioral health services. Prior to this platform’s integration, the call center staff was restricted in transitioning callers to community providers. The platform’s efficiency in promoting a smooth referral process enables the generation of electronic referrals, consequently lessening the workload for case managers and enhancing the service provided to 988 callers. In 2022, CSSNV case managers generated 2,172 referrals, accounting for almost three-quarters of the state’s total OpenBeds referrals. As of today, over two dozen significant healthcare organizations across Nevada utilize OpenBeds.

Beyond driving a surge in referrals, OpenBeds also enables CSSNV to better track the process. “OpenBeds time dates and stamps everything, so it keeps everyone accountable, not just us but also the provider organizations,” said Eteuati. “We want to be sure participants are actually getting the support they need, not just being given a number to call when they’re in crisis.”

“We love OpenBeds,” she concluded. “It is our number one go-to when we’re looking for treatment in Nevada for residents.”

  • 2,172

    referrals generated by CSSNV case managers in 2022

  • 75%

    total OpenBeds referrals in Nevada came from CSSNV

  • 24+

    other NV organizations using OpenBeds

About Bamboo Health

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.

Download Your Copy!

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BAYADA Home Health Care Leverages Real-Time Care Intelligence™ to Maintain In-Home Care

The Challenge

Many BAYADA clients are on Medicare while others hold private insurance, and a large percentage have mild, yet chronic conditions while others have acute conditions. Because of this, managing their populations was challenging. Clients were admitted to emergency departments (EDs) for an array of challenges, and BAYADA didn’t have real-time visibility into when and why those admissions occurred. Furthermore, upon discharge from the hospital or ED, patients weren’t always referred back to affiliated organizations, affecting the patient’s continuity of care.

BAYADA’s staff had no easy way of tracking individuals’ care journeys, making the efficient delivery of care and operations very challenging. At times, there would be a delay in hospital discharge, and the nurse would be deployed for follow-up care to find an empty home. At other times, nurses would be deployed to a client’s home for regular routine care, only to find out that the client wasn’t there because they had gone to the hospital for care. This would often become a costly, time-consuming process of manually calling other facilities to assess the situation and attempt to bring the patient back into follow-up care as needed.

Moreover, the nationwide expansion of the Home Health Value Based Purchasing (HHVBP) program only exacerbated these challenges and further highlights the need for real-time data and actionable insights for proper intervention. HHVBP relies on data coming from claims, Outcome and Assessment Information Set (OASIS), and Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHP) survey results. The complicated nature of balancing the highest quality of care, capping the overall spend and ensuring patients are receiving the appropriate care in a timely manner further adds to caregivers’ and care coordinators’ plates and makes HHVBP success that much more of a challenge.

The Solution

Enter Bamboo Health’s Pings™, which deliver real-time notifications whenever patients experience care events, whether they are at a hospital, ED or post-acute facility. First, BAYADA ran a pilot to test Pings in two offices in central North Carolina (towns of Guilford and Davidson), as a means of demonstrating value and return on investment of Pings across the company’s locations. There was an additional pilot in select parts of Florida, where BAYADA’s challenge was magnified.

In order to support those in the HHVBP program, Bamboo Health’s Pings solution enables continued patient engagement and care coordination when patients are discharged from home health services. The majority of HHVBP performance measures are linked to reducing unnecessary readmissions and ED presentations, so one of the most impactful ways home health agencies can increase HHVBP performance is through improving post-discharge care coordination and engagement.

For example, if an individual presents at the ED, a BAYADA Clinical Manager is aware via a real-time notification that provides the where, when and why. The ‘Ping’ also highlights if the patient is a multi-visit patient, which helps the Clinical Managers identify if different care is needed to reduce the likelihood of an unneeded admission, which in turn helps improve HHVBP Total Performance Score (TPS). After receiving a Ping, the clinical manager can communicate with the ED physician, helping to make the proper care decision, as well as reach out to the patient or their family directly to help ease concerns or educate them about BAYADA’s in-home service offerings.

As an added benefit, home health agencies can strengthen referral relationships with their health system partners by providing visibility into patient care transitions received from Pings. This not only improves continuity of care, but factors into better HHCAHP survey results, ultimately leading to a higher total performance score, too.

If a hospital admission is necessary for the patient, Pings also alerts BAYADA’s Clinical Managers of that admission, as well as any transfers and discharges so that in-home, follow-up appointments can be scheduled promptly. Receiving Pings provides new levels of informed awareness, proactive communication and results—all of which enable better quality performance under HHVBP.

The Results

Over a 90-day period in the North Carolina pilot, the Guilford office received 1,643 Pings and the Davidson office received 859 Pings. These real-time notifications allow BAYADA’s Clinical Managers to follow the paths of their clients in real time, which enhances care quality and eliminates unnecessary costs. Pings also helps the staff retain significant revenue for the business.

In North Carolina, an area that comprises roughly 1,800 clients on service, 200 employees and up to 500 admissions per week, BAYADA realized the following results:

patients recaptured over an 83-day period

in revenue saved over an 83-day period

decrease in missed care opportunities at Guilford over a 90-day period

decrease in missed care opportunities at Davidson over a 90-day period

Due to such success, BAYADA expanded the use of Pings to all of North Carolina, South Carolina and Pinellas County in Florida. In the first three quarters of 2022, BAYADA’s ‘Pinging’ locations in North Carolina, South Carolina and Florida received over 18,000 Pings from Emergency Departments. This translates to 46% of the total Pings volume received were due to their patients going to the ED, thus providing a key opportunity for  effective care coordination and follow-up care.

The implementation of Pings was a breeze, so our pilot was up and running quickly without any hiccups.

Immediately, receiving real-time alerts about our clients was like a breath of fresh air. To me, one of the worst downfalls to have as a home health agency is when we don’t get notified that a client has been discharged from the hospital, and that client is then home for days without anyone from BAYADA seeing them. That problem is eliminated by Pings and I can’t tell you how relieved we were to finally be able to follow their journey through the care continuum, understand what’s happening, and act. Having Pings has made us more efficient and effective in delivering care than ever before.

Jeanne Barton BAYADA Division Director, Eastern North Carolina and Florida

About BAYADA

In 1975, the ambitious and passionate Mark Baiada founded BAYADA Home Health Care based on a simple belief that everyone deserves a safe home life with comfort, independence and dignity. Since then, BAYADA has become one of the nation’s most trusted leaders in clinical care and support services at home, for both children and adults of all ages.

By hiring compassionate home health care professionals who share that same belief, BAYADA now provides a comprehensive array of home care services to more than 145,000 clients a year in 24 states and 7 international countries and growing. The foundation of its success is rooted in The BAYADA Way—the company’s guidepost that expresses its mission, vision, beliefs, and core values of compassion, excellence and reliability.

About Bamboo Health

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.

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Harbor Health Plan: Leveraging Pings to Monitor High Utilizers and Reduce Readmissions

The Challenge

Prior to implementing Bamboo Health’s Pings™ solution, the Harbor Health Plan team received a monthly spreadsheet listing their highest-cost members, along with the number of times those members presented to the emergency department (ED) within the 30-day window. The data included was typically anywhere from 60 to 90 days old, which made it difficult for the team to follow up with members. Harbor Health Plan was looking to implement a solution that provided insights into member events, in real time, from its surrounding hospitals and health systems in order to maximize its care coordination and member outreach efforts.

The Solution

Harbor Health Plan implemented Pings, a real-time notification solution when patients receive care across the continuum, in January of 2015. Bamboo Health onboarded and trained Harbor Health’s integrated care management team and provided recommendations on how to better integrate the platform into existing workflows.

Real-Time Notification Workflows

1. Pings is continuously monitored, providing care teams with real-time awareness of admissions and discharges.
2. Once a Ping is received, the team reviews the patient’s Care Team and Visit History information.
3. Team performs outreach to the patient’s care team, or drives to the organization where the patient is present.
4. Team determines appropriate care plans for the patient, and provides ongoing support. The report is divided among the integrated care management team members to review prior to performing outreach.
1. Pings is continuously monitored, providing care teams with real-time awareness of admissions and discharges.
2. Once a Ping is received, the team reviews the patient’s Care Team and Visit History information.
3. Team performs outreach to the patient’s care team, or drives to the organization where the patient is present.
4. Team determines appropriate care plans for the patient, and provides ongoing support. The report is divided among the integrated care management team members to review prior to performing outreach.

Implementation & Workflows

Each morning, Harbor Health Plan’s social worker runs a report in the Pings platform on members who have been admitted to or discharged from an acute care setting within the last 24 hours. The list is disseminated across team members, where the events are then color-coded and assigned to the appropriate person for follow up. Harbor Health Plan’s social worker is responsible for all inpatient discharges. The community health worker follows up on all ED discharges and maternity-related events, and the R. N. handles the events relating to complex care members.

The team has two business days to follow up with the member post-discharge to determine the reason for their admission, as well as to complete a health risk assessment. They then facilitate followup appointments with the member’s primary care physician (PCP). For members without an assigned PCP, the team will help to connect them with one within 24 hours, and schedule an appointment for them within seven days.

Daily reports allow care teams to monitor members who frequently present at acute care settings or may be at risk for readmission.

In many instances, the team finds that the readmissions are related to mental or behavioral health issues, lack of education on alternate settings where care can be received, a lack of PCP, or socioeconomic factors such as experiencing homelessness. The team will educate members,

connect them with medical and behavioral health services, develop care plans, or eliminate any other barriers the member might have to receiving care, in an effort to avoid further readmissions. Harbor Health Plan also uses the search feature in Pings to monitor any recent acute care events and continue outreach as needed.

After receiving a real-time Ping, the team will often intervene quickly by driving to the hospital or facility where the member is present. The team also uses Pings to learn more about the member’s care team. By having the care team contact information through Pings, Harbor Health Plan can reach out to them to discuss alternate care plans, prior visit histories, and any additional medical information, ensuring that the member receives the appropriate care.

Contact information for other care teams is available directly in workflows with Pings, so Harbor Health Plan can reach out to discuss alternate case options, prior visit histories and any additional medical information.

Harbor Health Plan Daily Workflows

Results & Impact

In just six months, Harbor Health Plan has seen a 7% decrease in readmissions for the high-utilizing members. They have also been able to flag 15 of their ERD “super utilizers” (defined as members who have presented to the ED two or more times per week), seven of which they have been able to engage to connect them with the appropriate medical or behavioral health services, resulting in a 40% reduction of ED visits for their high-utilizing members.

Decrease 7%

Recidivism For High-Utilizing Members

Decrease 40%

Reduction Of ED Visits For High-Utilizing Members

About Harbor Health

Harbor Health Plan, headquartered in Detroit, MI, is a Managed Care Organization (MCO) serving members throughout the state of Michigan. Harbor Health Plan was certified as a Clinic Plan in 1996, a Qualified Health Plan in 1998 and a licensed HMO in December 2000. Harbor Health Plan was purchased by Trusted Health Plan in March of 2018 and works to ensure that its members’ medical needs are met, recognizing that its providers are key to achieving this goal. Harbor Health Plan’s integrated care management team, which consists of a social worker, community health worker and a registered nurse, works with members faced with complex medical and behavioral health conditions. The team’s core objective is to reduce unnecessary hospital readmissions by connecting these members with the services necessary to ensure stable transitions back into the community.

About Bamboo Health

Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.

Download Your Copy!

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