Use Case Spotlight: Delaware Valley ACO Improves Patient Care Through Use of Real-Time Notifications

Use Case Spotlight: Delaware Valley ACO Improves Patient Care Through Use of Real-Time Notifications

How does Pings help you accomplish your goals?

PatientPing (Pings) helps us in a way that claims data cannot, by providing real-time event notifications across the continuum of care. For our Medicare population, being able to see the movement among post-acute providers was always a missing link. Since partnering with PatientPing (Bamboo Health), we have been able to track admissions and discharges within skilled nursing facilities, home health and hospice settings, and conduct outreach to patients and providers in a much more timely manner.  Our goals involve providing care coordination as an extension of the primary care provider, so PatientPing (Pings) helps us extend those services because we can identify the patient movement.

What do you like most about Pings?

We really love the format and simplicity of how the notification is delivered. Our team is more efficient because they are able to filter by type of provider, point of care, admit or discharge status, etc. It does not require analytical skills to search for information. One of the best features is the ability to connect the assigned care coordinator to the matching provider with enough contact information and/or customized message, so that providers are reminded to communicate with us. That feature has supported increased awareness of our services.

Can you give us a specific example of a time that Pings helped you help a patient?

A patient was admitted to a SNF with an anticipated length of stay of three weeks. About four days after admission to the SNF, the Nurse Care Coordinator observed a PatientPing (Pings) notification of discharge. The nurse contacted the facility and learned that the patient had signed out early—against medical advice—and stated that he was going home. Knowing this to be a high-risk patient, the nurse was able to work with social services to follow up with the patient at his home.  He was open to home health, which was then arranged.

With PatientPing (Pings), we were able to confirm that home health services had been implemented and could make sure they remained ‘active.’ Although there were other care coordination activities, we watched for discharge from home health so that other services could be offered. Had we not seen the early unanticipated discharge from the SNF, this patient would have likely ended up back in the emergency department facing a readmission. Because of this notification, we were able to act and offer other options.

What other technologies do you use (in addition to Pings) to help you accomplish your goals?

We have a population health platform from Wellcentive, which is also where many of our ambulatory care coordinators document or track caseloads. Additional supportive technology includes the John Hopkins ACG for risk stratification and MCG to help with condition specific assessments and care planning.  As a large ACO we also have technology to drive analytics and financial reports.

Thanks so much, Ann! For more information about how Bamboo Health can enhance your care coordination efforts, contact us.