The Challenge
The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services (CMHS) awarded Monarch a Certified Community Behavioral Health Clinic (CCBHC) Expansion Grant. The grant program was designed to provide individuals access to health services including 24/7 crisis intervention.
With the grant, we needed to be able to follow up with patients in a timely manner and provide coordination with other care providers… We never knew when our patients had been in the hospital until they reported it or told us 30 to 90 days later for a medication management follow-up.
Monique Lucas, BSN, RN, CCM, CCCTM Vice President of Integrated Care at Monarch
The Solution
A hospital partner mentioned a solution that could help: Pings™. The Pings solution delivers real-time notifications whenever patients experience care events across the continuum, allowing healthcare providers and health plans to better manage patient populations and coordinate care. Monarch began evaluating Pings to see if it could solve their issue of knowing where their patients are in real time to provide adequate and timely follow-up care.
Immediately recognizing its utility, Monarch implemented a Pings trial using some of the grant funding to cover approximately 1,500 of their patients.
Then, to prepare for Monarch’s participation as a care management agency for the North Carolina (NC) Medicaid Managed Care program launch, Monarch expanded its partnership with Bamboo Health for Pings by 10 times to cover all 28,000 lives within their patient population.
This was our first time working with a large federal government grant, and we had four months to comply with the requirements needed to become a certified clinical behavioral health clinic. We had a lot of work ahead of us to figure out how we were going to track and follow up with our patients.
Monique Lucas, BSN, RN, CCM, CCCTM Vice President of Integrated Care at Monarch
After about a year with Pings, we realized the value that it brought. We were able to utilize the data to build dashboards that gave us a clearer picture of what we were dealing with and how to handle our hospitalization population
The Results
Real-time visibility into patient care events
With Pings, Monarch’s care managers receive real-time alerts when their patients are hospitalized so they can check on the patient in the hospital as appropriate, pass along valuable information to the care team at the hospital, and promptly schedule post-discharge appointments and follow-up care.
In addition, they used Pings data to build a dashboard to see what was happening across their patient population. “It really opened our eyes to a lot of things we hadn’t realized,” Lucas said.
Here is some of the data they were able to integrate and visualize:
- Total Number of Hospital Visits
- Average Length of Stay
- Number of Pings Per Month
- Total Count of Visits By Setting
- Suicide-Related Visits
Once Monarch saw the basic data, they looked deeper into each category. For example, Monarch looked at patients with Pings to see the number of visits broken down by their primary diagnosis in their medical records. This breakdown of data gave Monarch a clearer picture of their high-risk populations and patients who need the most support.
Peggy Terhune, Ph.D., MBA, OT/L, President and CEO at Monarch, added: “The Pings solution allows Monarch to scale how we manage our mental health patient populations by giving our care teams a real-time look at performance trends and the ability to drill down to the patient level for a root-cause analysis that will support process-improvement initiatives. The healthcare landscape is changing rapidly to better support patients and quality health outcomes. Monarch is proud to have a partner like Bamboo Health that can directly support our organization’s strategy to comply with new government initiatives that can better serve our patients.”
Patient Success Story
While Monarch uses the data to meet grant requirements, it goes beyond that. They are now better equipped and more informed to meet the needs of their patients and provide whole-person care.
Lucas said one patient stands out as an example of how Pings enabled them to support their patients: “A young woman had lost a son and had worked with us on her recovery with the care manager, medication management, peer support, as well as group and individual therapy. She progressed well, so, like other agencies, as patients get better, they come to us less frequently for care. Fast-forward to the anniversary of her son’s death which was so hard for her that she ended up in the emergency room. We got a Ping in real time to let us know she was there. We called her at the hospital, and she burst into tears, expressing her immense gratitude for us reaching out,” Lucas said. “She needed us to call her. Without that real-time insight from Pings, we wouldn’t have known to re-engage her care and be there for her. And guess what? She is now a volunteer for our peer support recovery teams.”
Through care coordination, the Pings solution has enabled Monarch to better serve their patients while they are hospitalized: “We had another patient participating in our Medication Assisted Therapy (MAT) program. The patient had been doing well, but unfortunately, fell ill and had to be hospitalized,” Lucas shared. “We are only required to follow-up for behavioral health hospitalizations for our value-based contracts, but we got the Ping that the patient was there and our care manager followed up. Our psychiatrist was able to communicate with the doctors in the hospital, resulting in no break in that continuity of care and no disruption to the medications that were aiding the patient’s recovery.”
About Monarch
Monarch is a North Carolina statewide provider of comprehensive specialty mental health and human services that serves 28,000 patients with intellectual and developmental disabilities, mental illness and substance use disorders.
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.
