We sat down with Tina Zurita, Director of Quality Management at NextLevel Health, a Medicaid Managed Care Organization (MCO) serving Medicaid beneficiaries and members participating in the Managed Long-Term Services and Supports program. Tina shares how her team uses Bamboo Health (formerly Appriss Health and PatientPing) solutions to improve care collaboration efforts and member outcomes.

Thanks so much, Tina!

See how partnering with Bamboo Health can enhance the care your team delivers to patients. Contact us to learn more.

For our latest Four Questions Series, we sat down with Shelly Kent, care manager at Perrysburg Family Physicians, LLC., an independent family practice located in Perrysburg, Ohio. Perrysburg has five affiliated physicians within its practice who provide care to over 6,600 patients. As a participant in Track 2 of CMS’ CPC+ model, Perrysburg Family Physicians is focused on improving care outcomes for patients while reducing overall care costs.

PatientPing became Bamboo Health in 2021.

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For our latest Four Questions Series, we sat down with Shannon Parrish, Director of Care Coordination at CHESS, a NextGen ACO located in High Point, North Carolina. CHESS is a physician-led healthcare service organization that is supporting its participating physicians and health systems to provide improved, value-based care to the patients they serve. As a NextGen ACO, CHESS is focused on identifying key areas of care that result in high costs and wasted resources.

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For our latest Four Questions Series, we sat down with Erik Iverson, VP of Business Development at Legacy Healthcare located in Skokie, Illinois. Legacy Healthcare provides skilled nursing, rehabilitation, and specialized services to patients across 32 facilities throughout the Chicagoland area, as well as in Utah and Montana. Legacy aims to provide personal, empathetic, and customized care to each of the patients they serve.

What are some of the care coordination challenges your organization has faced?

One of the biggest care coordination challenges that we have faced at Legacy is knowing what a patient’s’ care journey looks like prior to them entering our doors. We often receive information on a patient’s most recent event, but we’re missing the important information about what happened to them before that. If an 80-year-old woman comes to receive care at one of our facilities after a hospital visit, we may know what happened to her at the hospital, but what about the 80 years before that? Without this information, we’re in the dark on patients’ medical histories, who their care providers are, whether or not they see specialists, etc. We then have to piece information together to develop an effective care plan.

Another challenge has been monitoring our patients post-discharge. It’s been difficult to ensure that patients are following up with their PCPs and continuing the services they need in order to stay healthy. Additionally, patients don’t always know that they can come back to our facilities to receive care and turn to the ED instead which results in costly, unnecessary readmissions.

How have you overcome these challenges?

Technology has been a big part of overcoming these challenges. Without it, it’s difficult for our staff to stay on top of care events, and information can easily fall through the cracks. Technology like PatientPing (Pings) helps us by enabling our staff to act on patient events faster.

With PatientPing (Pings), we’re able to see the patient’s journey prior to them admitting to one of our facilities. PatientPing (Pings) also gives us the patient’s care team contact information, enabling collaboration with other providers on appropriate care plans. This has not only helped ensure that we’re providing the right services, but it’s also helped us build relationships with our surrounding hospitals and health systems. As a SNF, if our readmission rates are too high, we may be not considered for certain partnerships. Having information at our fingertips through PatientPing (Pings) has helped us maintain certain benchmarks, perform better, stay ahead of our competition and provide better care to our patients.

Through PatientPing (Pings), we’re also able to monitor patients post-discharge. We are notified as soon as patients present to an ED, allowing us to intervene and direct patients back to our facilities when appropriate. Not only does this avoid unnecessary ED visits, but allows us to provide continued support to the patients we serve.

How has Pings helped you achieve your goals?

With a lot of technology today, it may look exciting, but it may also force us to do things outside of our day-to-day. The beauty of PatientPing (Pings) is that it’s been easy to integrate into our existing workflows.

Before PatientPing (Pings), figuring out who a patient’s PCP was or determining whether they had seen a specialist was both tedious and time-consuming. Now, we’re able to see this info days before the patient is admitted to our facilities, putting us ahead of the game. We’re able to plan ahead for LOS expectations and post-discharge follow-ups, making the patient’s stay much smoother.

We’ve also strengthened our relationship with hospitals. Because we’re notified when a patient presents to the ED post-discharge, we are able to inform them that the patient doesn’t necessarily need to be admitted and can come back to receive care at our facility.

Overall, PatientPing (Pings) benefits everyone involved. Providers always want to do what is best for the patient, but when the information they need isn’t readily available, that can be hard to do. With PatientPing (Pings), all of the information is there and now we’re able to focus less on worrying about these logistics and more on improving care for patients.

Can you tell us about a time when Pings helped you help a patient?

When we receive Pings on our discharged patients who present to the ED, we often perform what we call “wellness checks”, where we send someone from our facility to drive to the ED and check in on the patient.

In one instance, we sent a liaison to a nearby hospital to check on a patient who had been sitting in the ED for over 6 hours with her husband. The liaison learned that the patient did not feel well and wasn’t operating well at home. The liaison then informed the patient that she was able to come back to our facility to receive care for no additional cost. We were able to set her up with transportation back to our facility where she received rehab services for a week in the comfort of our SNF.

In this case, the patient was unaware of her care options and went to the ED to receive support. With PatientPing (Pings), we were able to avoid costly, unnecessary hospital admissions and also provide continuous support to the patient and her family.

For our latest Four Questions Series, we sat down with Tim Carey, director of data and performance analytics at BaneCare Management. BaneCare Management operates 12 skilled nursing facilities throughout Massachusetts, and is a trusted family-owned senior services company that has been a leading provider of rehabilitation, skilled nursing, assisted living and adult day health for nearly six decades. BaneCare is driven to creating an environment built on compassion, dignity, and respect for residents and their extended families, as well as for its community and staff members.

Can you tell us about some of the care coordination challenges your organization has faced in the last few years?

In my world of data and analytics, some of the care coordination challenges that we face are around data integrity. At BaneCare, we work extremely hard to provide accurate data. When we meet with organizations that we work with, there are times where our data on patients’ care events doesn’t match up. For example, we recently met with a hospital and an ACO who both monitor patient events in EHRs. The hospital and ACO saw that one patient was documented as being discharged home with VNA services when that same patient was actually receiving care at one of our facilities. This fragmented data for the hospital and ACO creates various challenges, especially for the clinical staff who are responsible for following patients during their care journeys.

How have you overcome these challenges?

At BaneCare, we are continuously stressing the importance of communication and leveraging PatientPing (Pings) to accurately monitor where patients are going. With PatientPing (Pings),  we can see in real time whenever and wherever patients go to receive care. This has helped us strengthen relationships with other organizations in the community because we can collaborate more closely to reduce readmissions and help get patients to the right care settings at the right time.

What insights do you have now that you lacked prior to implementing Pings?

With PatientPing (Pings), we’re able to see the “big picture” and follow patients as they move from care setting to care setting. Prior to PatientPing (Pings), this was complicated for us. I remember a time a few years ago when I was a business analyst at a local community hospital. I needed to find information on SNF readmission rates, but in order to do so, I had to go through a very long and time consuming process. Now, fast forward a few years, and we have PatientPing (Pings) to provide this information and pull these analytics for us.

PatientPing (Pings)’s reporting also continues to improve, and helps us to standardize our required monthly reporting by telling us admission activity, ALOS and 30-day readmission rates. This helps us to standardize and automate the reporting process between organizations across the continuum.

How has Pings helped you improve patient care?

We use PatientPing (Pings) for process improvement efforts, specifically to monitor patients presenting to a hospital after they’ve been discharged from a SNF. It’s important for us to determine reasons for admissions so that we can improve our discharge planning processes and care for patients in return. At BaneCare, it’s all about continuous improvement, so we are always using data–like the data we receive from PatientPing (Pings) –to help drive those efforts.

For example, our facilities receive notifications from PatientPing (Pings) as soon as a patient presents to a hospital. From there, we’re able to work with that hospital in real time, and direct patients back to SNFs when appropriate. This collaboration helps to not only reduce unnecessary readmissions, but also improves the care provided to patients by getting them to the right care setting at the right time.

Learn how Pings can help your organization coordinate care.  Contact us today.

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.

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For our latest Four Questions Series, we sat down with Joe Kachelski, CEO of the Wisconsin Statewide Health Information Network (WISHIN), to get his thoughts on value-based care, challenges he’s seeing in the healthcare space, along with how Bamboo Health has helped make an impact since partnering with WISHIN earlier this year.

WISHIN is an independent not-for-profit organization which works to successfully provide health information technology to patients and caregivers through its statewide health information network. WISHIN’s existing network consists of physicians, clinics, hospitals, pharmacies, clinical laboratories, and health plans located throughout Wisconsin.

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