The Challenge
Houston Methodist (HMCC) joined Track 3 of the Medicare Shared Savings Program (MSSP) in January of 2017. At the time, HMCC had little insight into patients’ post-acute care (PAC) activity. They relied on quarterly data from the Centers for Medicare and Medicaid Services and phone calls to skilled nursing facilities (SNFs) to locate patients. Given that the data was lagged and the fact that it often took multiple tries to get ahold of SNFs, HMCC typically only found out about patient events 10 to 15 days after they occurred.
Knowing that HMCC was an outlier in the PAC space, the organization was in need of a solution that would help monitor patient events in real time to improve their care coordination efforts and succeed under MSSP.
“[Bamboo Health] has opened our eyes to the PAC world. We can now see the trends of where our patients are going and ensure process improvement, intervene on care events and receive more insights on our patients.”
Janice Finder Director of Population Health, Houston Methodist Coordinated Care
The Solution
Just two months after signing the contract, HMCC used Pings™ at over 190 sites of care, including provider organizations, hospitals, SNFs and long term acute care facilities (LTACs).
To begin the onboarding process, Bamboo Health provided participating organizations with in-person demos of the platform and equipped them with best practice toolkits with tips on how to best integrate Pings into their daily workflows.
HMCC’s project specialist logs into the platform at the start of each day to view a customized report on all patients who have been admitted to or discharged from a PAC or emergency department setting. The project specialist then assigns all events to the appropriate care team member. HMCC’s partner, Evolent Health, manages five post-acute care facilities and all LTAC admissions and discharges. HMCC’s medical director is responsible for all other care events.
In addition to monitoring the web application throughout the day, HMCC’s project specialist also utilizes text and email notifications to receive push alerts on patient events.
When a new event occurs, the HMCC team reviews the patient’s visit history and care team information to determine next steps for outreach. HMCC then either calls the facility where patients are located, or contacts a member of their care team to ensure that the appropriate services are provided. This also offers HMCC an opportunity to update the patient’s information, as well as to relay critical patient information to the rest of the care team.
HMCC uses saved filters to access events for specific subsets of patients. Some of these filters include the “SNF Admit Filter” to see patients who have been admitted to a SNF, and the “LTAC Discharges Filter” to see those patients who have been discharged from a long-term care facility.
Additionally, HMCC provides Bamboo Health with a roster of their patients belonging to bundled payment programs so that they can more efficiently monitor those patients across their entire episode of care.
The HMCC team meets weekly to review all admissions and discharges from the previous week to ensure that follow ups have been made and that patients are receiving care in the appropriate care setting.
The Results
Since implementing Pings, HMCC has:
- Reduced length of stay for its managed patients from 25 days
to 21 days, resulting in $681,000 in savings. - Earned $1,258,180 in shared savings under CMS’ Medicare Shared Savings Program in one year.
- Doubled the number of patients receiving care in their post-acute network.
- Refined and expanded its preferred PAC network.
- 100% of HMCC’s post-acute partners use Pings.
[Pings] is a much-needed platform for our relationship with HMCC, and allows us to follow patients’ movements in real time. The easy-to-use solution provides our corporate team with the ability to monitor and hold our care teams and post-acute partners accountable for quality patient outcomes. We set notifications to alert our teams when an ACO patient admits to one of our facilities–the communication and data accompanied with patients’ profiles helps with transitioning patients from acute settings and serves as an effective tool for our interdisciplinary teams. Without [Pings], the trajectory of patients and cross-functional communication between acute and post-acute would be almost impossible.”
Ron McGaughy Vice President of Network Development at HMG Healthcare, LLC
Patient Success Story
HMCC received a Ping on a patient who was admitted to a SNF in Connecticut. The team quickly reached out to the patient’s family to follow up and discovered that she had fallen while visiting a friend. The patient had received inpatient care and was then discharged to a SNF to receive care for her injury. The HMCC team was able to connect the family with a primary care physician (PCP) in Connecticut to ensure that the patient was receiving the care she needed. HMCC then relayed this information back to the patient’s PCP in Texas, who was unaware of the patient’s care event.
Without Pings, both HMCC and the patient’s PCP would have been unaware of the patient’s care event and her whereabouts. Additionally, HMCC would not have been able to facilitate a follow up with the patient or connect her with the services she needed while out of state.
About Houston Methodist
Houston Methodist Coordinated Care (HMCC), located in Houston, Texas, is an Accountable Care Organization (ACO) led by physicians affiliated with Houston Methodist and the community. Houston Methodist’s network consists of seven full-service hospitals, 98 employed physicians, and 30 independent physicians located throughout the state. HMCC ensures that its participating providers are supported with the tools and resources they need to improve care quality and safety for the patients they serve.
Houston Methodist began using Pings in July of 2017, expanding Bamboo Health’s presence in Texas. The two organizations hold a unique partnership and work together to improve statewide care coordination.
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.
