Kevin Hutchinson, current founder & CEO of MyTaskit shares his insights in the next edition of our Four Questions blog. With an extensive background in healthcare–from being the Former Founding President & CEO at SureScripts to advising multiple growth-stage companies, Kevin’s insights and knowledge are invaluable to Bamboo Health.
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Vince Kuraitis, advisor and strategic healthcare consultant, connected with Bamboo Health’s Jay Desai on the potential for healthcare to transform into a platform industry: Think Facebook, Google or Amazon. To Vince, healthcare desperately needs to capitalize on the network effect, but this can’t happen until healthcare embraces platform companies to support this business model.
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Welcome to another edition of the Four Questions blog series. This time, we’re sitting down with Sean Cavanaugh, former Head of Medicare to talk care coordination, payment reform, and challenges facing healthcare providers today.
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PatientPing (Pings) helps us in a way that claims data cannot, by providing real-time event notifications across the continuum of care. For our Medicare population, being able to see the movement among post-acute providers was always a missing link. Since partnering with PatientPing (Bamboo Health), we have been able to track admissions and discharges within skilled nursing facilities, home health and hospice settings, and conduct outreach to patients and providers in a much more timely manner. Our goals involve providing care coordination as an extension of the primary care provider, so PatientPing (Pings) helps us extend those services because we can identify the patient movement.
We really love the format and simplicity of how the notification is delivered. Our team is more efficient because they are able to filter by type of provider, point of care, admit or discharge status, etc. It does not require analytical skills to search for information. One of the best features is the ability to connect the assigned care coordinator to the matching provider with enough contact information and/or customized message, so that providers are reminded to communicate with us. That feature has supported increased awareness of our services.
A patient was admitted to a SNF with an anticipated length of stay of three weeks. About four days after admission to the SNF, the Nurse Care Coordinator observed a PatientPing (Pings) notification of discharge. The nurse contacted the facility and learned that the patient had signed out early—against medical advice—and stated that he was going home. Knowing this to be a high-risk patient, the nurse was able to work with social services to follow up with the patient at his home. He was open to home health, which was then arranged.
With PatientPing (Pings), we were able to confirm that home health services had been implemented and could make sure they remained ‘active.’ Although there were other care coordination activities, we watched for discharge from home health so that other services could be offered. Had we not seen the early unanticipated discharge from the SNF, this patient would have likely ended up back in the emergency department facing a readmission. Because of this notification, we were able to act and offer other options.
We have a population health platform from Wellcentive, which is also where many of our ambulatory care coordinators document or track caseloads. Additional supportive technology includes the John Hopkins ACG for risk stratification and MCG to help with condition specific assessments and care planning. As a large ACO we also have technology to drive analytics and financial reports.
Thanks so much, Ann! For more information about how Bamboo Health can enhance your care coordination efforts, contact us.
PatientPing (Pings) provides a central, timely repository for patient ADT information at organizational, practice unit, and provider levels. We use this information to help with transitions of care, as well as to identify trends and opportunities for patient education on subjects such as practice after-hours and same-day appointments.
We particularly like the volume of entities contributing to ADT feeds, as well as the support from PatientPing (Bamboo Health) staff.
The admit and discharge data obtained through the PatientPing (Pings) interface allowed one of our physicians to easily identify a patient who was presenting at the emergency department of a local hospital multiple times in a short time window. Specifically, this patient presented to the ED three times in the span of 15 days.
Using this information, the patient’s primary care provider and staff made it a priority to not only schedule a follow-up with this patient after the first ED visit, but also for education that stressed the availability of same day appointments, after-hours services, and options for additional consultation without a regular scheduled office visit. Since these events, the patient’s condition has been effectively managed and he has not presented to the ED.
In addition to PatientPing (Pings), we use the following to help us with our care coordination and engagement initiatives:
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PatientPing (Pings) allows us to coordinate care for our patients as they move from care location to care location. Prior to PatientPing (Pings), we were really in the dark when it came to understanding the where and when of our patients. At that point, the only insight we had into the whereabouts of patients was through outdated claims data or when they showed up on our primary care doorstep or, worse, ended up in the ER again. We lacked the tools to proactively manage our patients. PatientPing (Pings) has allowed us to meaningfully manage our patients in real time so we can give them the right care at the right time, and ensure that their care transitions are safer.
PatientPing (Pings) is one of the most user friendly IT tools we have encountered, and we use many, many platforms on a daily basis. PatientPing (Bamboo Health) understands the different customers that are using their product and customizes the data output to match their needs. The PatientPing (Bamboo Health) team is also very receptive to feedback. When users give feedback, the team works hard to make changes to the product that incorporate the ideas from the community. And they always make timely adjustments should any technical issues arise.
PatientPing (Pings) helps us help patients every single day. By using the tool, we know exactly when our patient is sent home from a skilled nursing facility, as well as which visiting nurse agency will be caring for them at home. This allows our nurses to call the patient on the day of a SNF discharge and ask if he or she has been visited by the nurse. If the nurse has not come within 24 hours, we can then follow up with the appropriate agency to ensure that they care for our patient when he or she needs it most. Prior to using PatientPing (Pings), our patients were more or less on their own until we became aware that they were home. And that was only if we even knew they went to a SNF. Using this tool is a huge leap forward in being able to care for our patients when they need it most.
We use quite a few technologies at the ACO. We sit on a huge claims database. We also have multiple risk stratification software applications and analytics, a secure texting platform, and multiple EMR systems.
Thanks so much, Adrianne! For more information about Bamboo Health can enhance your care coordination efforts, contact us.
The triple aim of an Accountable Care Organization is to improve patient care, patient quality and reduce costs. Reliance ACO is unique in that we follow every single patient who enters or leaves an emergency room or hospital setting. We have a full time medical director who contacts the ER to ensure that patients are not improperly admitted. By providing real-time information, PatientPing (Pings) allows us to know when and where our patients are receiving care.
In addition, we have developed a program to follow our patients who discharged to post acute settings. Our director of this program checks PatientPing (Pings) every single day to see which of our patients are admitted to our preferred SNFs so that our nurse coordinator can immediately follow up on them. If our nurse coordinator is not advised of a discharge, PatientPing (Pings) lets us know and the information is forwarded to our care coordinator to make sure that the patient is seen by the PCP within 7 days. PatientPing (Pings) is so useful to us in a post acute setting that we won’t certify a post acute facility as a preferred provider, regardless of quality, unless they have PatientPing (Pings). PatientPing (Pings) is a necessary tool to ensure a smooth transition of care and without it, patients fall through the cracks and are not followed up with in a timely manner.
I like the fact that the program is constantly being improved and upgraded. We have been in the ACO program for 2 ½ years. During this period, we have constantly tried to improve our coordination of care. This means constantly improving the tools that we use. PatientPing (Pings) has helped us achieve this.
I am impressed with the fact that the information is in a very readable form. We can tell at a glance which patients are in which facilities. Also, the patient history is extremely useful for tracking patients. Reliance ACO is made up of independent physicians. We have to watch our costs carefully. PatientPing (Pings) is cost effective for a group like ours.
Since we use PatientPing (Pings) every single day and manage to avoid several hospitalizations per day because of timely information, there is not one example, but literally hundreds of examples over the course of six months where it has been invaluable in preventing unnecessary admissions. And, more recently, as we have expanded the program to SNFs, it has been invaluable in ensuring improved coordination of care.
Our care coordination program is called Synapse. We use it to help manage our complex patients. The system automatically upgrades a patient to a more complex tier when they receive their second hospitalization. The ADT feeds that we receive from SEMHIE are fully integrated into our system so it is part of the patient file. We also have a phone application that notifies the PCP of all ADTs on a real time basis. The phone app contains a list of all complex (we call them Tier 3) patients for the doctor. If the doctor fails to open the information, our program administrator is aware of it and we can follow up to make sure the patient is seen after discharge. The phone app is automatically updated each month when we receive new claims information and new patients.
Thanks so much, Gene! For more information about how Bamboo Health can help improve your care coordination efforts, contact us.
