In our latest Four Questions Series, we sat down with Kimberly Sorace from Partners in Care ACO located in East Brunswick, New Jersey. As nurse care coordinator and practice transformation coordinator, Kimberly is in direct contact with patients across 15 practices to monitor their admissions and discharges to improve care coordination and transitional care management workflows.
What are some of the care coordination challenges your organization has faced?
Not being able to monitor our patients’ transitions of care has been a huge challenge for us. There was really no simple way of knowing where our patients went to receive their care, which created a disconnect for us. As an ACO, our main goals are to improve quality and reduce the cost of care and length of stay (LOS) for our skilled nursing facility (SNF) partners, while also reducing hospital readmissions. We set the expectation for our physicians to take ownership of effectively managing their patients’ events, however, you can’t manage what you don’t know. Without a way for physicians to monitor patient events, effective care coordination is nearly impossible.
How did you overcome these challenges?
We implemented PatientPing (Pings) this year, and it’s been instrumental in helping us to overcome these challenges. It’s almost as though I don’t know where we were prior to having PatientPing (Pings), or how we lived without it–it’s that valuable. We went from not being able to get a handle on our patients to being able to manage their events in real time. In the past, we were relying on the patients or caregivers to make appointments with PCPs following discharge. Now that we’re receiving Pings, we’re able to quickly intervene to notify providers on patient events and apply appropriate transitional care management (TCM) services. This is all huge from an ACO standpoint because we are able to better manage cost reductions and readmission rates.
How has Pings helped you achieve your goals?
We’ve used PatientPing (Pings) to set goals around cost reductions across our network, as well as to gain insight into our average LOS and SNF utilization. With PatientPing, (Pings) we are able to monitor our SNF patients with notifications whenever our patients are admitted or discharged to or from a SNF. We also use PatientPing (Pings)’s filters to find patients who might be over the typical LOS range. We then contact the patient’s PCP to determine if a different care plan is needed. This has helped us create workflows around our SNF patients, and in turn reduce readmissions and successfully apply transitions of care management.
Can you tell us about a time when Pings helped you help a patient?
We recently received a notification on a patient who had been frequenting several hospitals in the area. Once we received the Ping, we were able to reach out to the patient and coordinate a visit with his PCP, who had until then been unaware of the patient’s hospital admissions. Upon the visit, the physician was able to speak with the patient and inform him that many of his care events could be addressed in the PCP’s office. In this case, the patient simply needed the reassurance and education from his doctor, which can sometimes go overlooked.
Thanks so much, Kimberly! For more information about how Bamboo Health can enhance your care coordination efforts, contact us.