Eleanor Health provides value-based substance use disorder (SUD) and behavioral health care management services to its 1,000+ community members in over 12 locations across six states: North Carolina, New Jersey, Massachusetts, Washington, Louisiana, and Ohio. Through medications for substance use disorder (MSUD), therapy, psychiatry, nurse care management, and community-based resources, Eleanor takes a whole-person approach that fosters long-term physical and mental health recovery. Eleanor’s suite of outpatient services meets the patient where they are through telehealth appointments, clinics, community settings, and field-based teams.
We sat down with Ben Hall, SVP, Head of Product Strategy and Alex Piersiak, Director of Marketing, Member Growth & Engagement from Eleanor to discuss how their team approaches care coordination in a value-based care world, challenges they face in this endeavor, and how Pings helps improve patient outcomes.
Appriss Health and PatientPing became Bamboo Health in 2021.
What are some of the care coordination initiatives your organization focuses on?
Ben: From day one, Eleanor Health has operated with a mission of treating the whole person, which innately requires the coordination of long-term care in a value-based setting. To succeed at this, we must collaborate with other health care providers like emergency departments, primary care physicians, and inpatient treatment providers. Effective care coordination helps us contribute to what we call a patient’s “recovery capital score,” which is more than just clinical outcomes; it includes their job security, living in a safe environment, and family involvement in their recovery. As a value-based care driven organization, we also take on financial risk at both the individual and population level to drive home our mission of helping people affected by addiction live amazing lives.
Alex: Moreover, we like to refer to ourselves as a medical home that specializes in substance use disorder and mental health. So, it is not just our goal, but our purpose to address addiction, mental health, social determinants of health, and physical health in conjunction with the coordination amongst such efforts.
What challenges has your organization faced in succeeding under these initiatives?
Alex: Timeliness is key. Care coordination cannot happen properly without near real-time follow up because that determines the success of building relationships with our members as well as their engagement in their treatment and recovery journey. From events ranging from an emergency room discharge to something such as a patient’s birthday, it is key that that outreach happens within 48-72 hours in order to truly improve patient care and engagement.
Ben: Plus, it is very time consuming, inefficient, and unproductive to have to work to connect to every hospital or HIE in each of our markets. To get that visibility and scale of a network, especially when you’re growing quickly and operating in multiple states like we are, it’s a non-starter to have to build those connections ourselves for care coordination purposes. We wanted to supplement what we get from our EHR’s connectivity across the nation with other networks that exist, and PatientPing is a one-stop-shop for it all.
How has PatientPing helped play a role in overcoming some of these challenges?
Ben: We luckily started using PatientPing early on in Eleanor’s life as an organization, but before PatientPing, we relied on self-reported medical histories, outcomes, and care events from our patients. The PatientPing platform has proven to us that members typically under report care events, but since PatientPing gives us real-time alerts, we are equipped with the knowledge and insight needed to best care for our patient population.
Alex: We have two teams at Eleanor that actively use PatientPing for different subsets of our member base, and the platform helps each team promptly engage with patients. One team receives Pings (PatientPing’s real-time notification system) for populations that our health plan partners attribute to us based on SUD risk factors or diagnoses, which allows them to proactively reach out and keep recovery services top of mind. That team also uses PatientPing to reach out after a care event to prospective members that were formerly interested in our services, but never fully engaged, in order to see if now is a good time to meet with us. The second team is our nurse care managers that monitor Pings for patients who had an appointment with us in the last 60 days, who we call active members. These Pings prompt the nurse care managers to conduct a wellness check to coordinate care with their primary care physician (PCP) or schedule a follow-up appointment with us if necessary.
Additionally, PatientPing gives both teams the most up-to-date contact information, which can be hard for the population we serve since our patients may have housing instability or call from different phone numbers.
Can you tell us about a time when PatientPing helped you to improve care for a member?
Ben: Our clinic manager received a Ping that one of our members had relapsed, and unfortunately this member had been unengaged in their care with Eleanor for some time. When our staff member reached out, the member told them that they weren’t going to let Eleanor know what happened because they felt ashamed, but they were so grateful that Eleanor reached out to check in. The member felt incredibly cared for and the best part is that this member reengaged in their care with us after we reached out!
