The Challenge
Prior to implementing Bamboo Health’s Pings™ solution, Pioneer Valley Accountable Care (PVAC) lacked standardized communication protocols with their skilled nursing facility (SNF) partners. While primary care physicians (PCPs) would occasionally receive discharge packets from SNFs, SNFs within PVAC’s network were unable to identify if one of their patients was a part of PVAC’s accountable care organization (ACO). SNFs worked only from a paper list of PVAC’s PCPs. They relied exclusively on this list to match patients to PVAC by their attributed PCP, leading to inaccurate PVAC patient identification. This antiquated process made it challenging for PVAC to hold facilities accountable for care quality and instruction adherence for their patients.
When PVAC initially began looking for technology to implement, one of their biggest concerns was ensuring that their post-acute partners’ workflows were not disrupted unnecessarily. They felt strongly that technology should fill gaps and be simple to use. PVAC knew how important it was to engage their partners immediately with the new platform, so PVAC spent close to a year engaging with the post-acute providers to better understand how they were using Pings and to make sure that it was fully engrained in their workflows.
The Solution
PVAC partnered with Bamboo Health to use Pings, a real-time notification tool, to receive alerts on their patients’ events. Once PVAC and their SNF partners implemented Pings, all parties could identify in real-time whenever PVAC patients were admitted and discharged from their SNFS as well as accurately recognize whether a patient was attributed to PVAC. Through Pings, the facilities also now had information about the patient’s PCPs and, critically, how and when to contact the ACO care manager.
Furthermore, the ability for PVAC to standardize discharge communications with their SNFs through Pings was critical to improving care quality around transitions. SNFs now receive standardized discharge instructions for all PVAC patients that specify PVAC’s discharge summary requirements and communication protocols. This was an instrumental step forward for the SNFs-ACO partnership, as the SNFs now know not only how to get in contact with PVAC, but also what to do to maximize care for PVAC’s patients.
By using Pings, PVAC is now able to monitor compliance and develop a culture of accountability across its SNF Network. PVAC relies on a care management team to oversee utilization review and care management for their patients in SNFs. This requires SNFs to keep their data up-to-date (meaning patient data must be inputted in the Pings platform within 24 hours) so PVAC knows where their patients are seeking care at all times.
Based on the success of their SNF network, PVAC is implementing similar care protocols with their hospitals for inpatient events. Through Pings, PVAC also receives notifications when one of their patients is admitted to a hospital, emergency room or being seen by the Visiting Nurse Association (VNA). These care teams can then see the personalized care instructions for high- and average-risk PVAC patients and engage in the appropriate communication and transitions in care protocols designed for PVAC patients to safely transition to the next site of care.
Pings was and is an invaluable tool helping us to seamlessly deliver coordinated care at the right place at the right time for our patients. It allows us to connect in real time with partners in our patient’s care team that were previously invisible to us because we simply didn’t know where our patient had gone. It’s a simple, but eloquent solution to some of the pitfalls with managing patients across the care continuum.
Dr. Adrianne Seiler Medical Director of Pioneer Valley ACO
The Results
PVAC receives a notification that one of their patients, Mary Smith, is at Baystate Medical Center (BMC). PVAC can see how long Mary’s been at BMC and if she is a frequent flier. PVAC can call other facilities to coordinate Mary’s care because they have more insight into long-term discussions regarding her care plan. The PVAC inpatient case manager can call the outpatient care manager and let them know, for example, that Mary is going to a preferred SNF and was started on a new anticoagulant medication. Once the patient goes to the SNF and the SNF admissions coordinator enters Mary’s information into the Pings platform, the SNF can see that she is a PVAC patient. They flag her profile as such, and proceed to follow the care protocol for Mary provided through Pings. PVAC’s SNF care manager receives notification that Mary is in the SNF and is able to follow Mary’s care there. Once Mary is ready for discharge, the SNF can send the standardized SNF discharge packet to the PCP and PVAC care manager. VNA was arranged for Mary and Mary’s PVAC care manager receives notification in the Pings platform when the VNA nurse has seen the patient and the VNA nurse can follow PVAC’s VNA care protocols.
$13,300
SNF average cost per case baseline
$10,033
SNF average cost per case with technology solutions
-25%
decrease
Key Outcomes
- Improved care coordination
- Refined and engaged post-acute network
- Delivered appropriate post-acute utilization
- Decreased overall costs
About Pioneer Valley Accountable Care Organization
PVAC is an ACO located in western Massachusetts serving Medicare fee-for-service beneficiaries throughout the Pioneer Valley. PVAC has a 21-member Board of Managers, consisting of 14 physicians and three health system executives, all of whom are PVAC provider participants, two managed care organization executives, one Medicare FFS beneficiary, and one Consumer Advocate. The Board of Managers oversees PVAC’s operations and strategic direction.
PVAC is affiliated with Baycare Health Partners, Inc., a physician-hospital organization that serves the four Baystate Health hospitals and about 175 medical practices with approximately 1,400 physicians. BayCare is an alliance of the medical staff and Baystate Health hospitals, and collaborates in improving the quality, safety, efficiency, and sustainability of healthcare in their community.
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.
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.
