Eagle Physicians & Associates Improves Transitional Care With Pings™

The Challenge

As trends shift toward value-based care, Eagle Physicians has remained focused on improving its Transitional Care Management (TCM) services. Prior to refining this process, Eagle Physicians’ primary care providers (PCPs) were responsible for all TCM services via standardized documentation. Patients leaving acute care settings often lacked the support services necessary to ensure medication adherence at home and were not always able follow through with discharge instructions and follow-up appointments.

Eagle Physicians partnered with two health plan organizations to manage patients covered under certain plans, created a Transitions of Care Team to work directly with the health plan teams and develop a Centralized Quality Team to manage care transitions.

Under this workflow, the team distributed a daily report on patient admissions and discharges from its hospital system to all Eagle Physicians practices. The report was specific only to the hospital system, meaning that the Centralized Quality Team had to run additional internal reports to accurately identify Eagle Physicians’ patients. Eagle Physicians would follow up with patients within 7 to 14 days, depending on the patient’s acuity level.

Because the data provided by the hospital system was delayed and sometimes inaccurate, the team ineffectively monitored patient events, resulting in missed opportunities to facilitate patient follow-up appointments, reconcile medications and follow through on discharge plans. Eagle Physicians implemented an additional database in hopes of obtaining more streamlined patient data; however, the system still required data manipulation to gain relevant insights and did not monitor skilled nursing facility (SNF) patients. The team also had to create weekly reminders within their electronic health record (EHR) to call SNFs to monitor patient status.

Since the process was ineffective and time-consuming, Eagle Physicians looked for a solution that would allow them to monitor patients’ care transitions real-time and facilitate timely follow-ups.

The Solution

Eagle Physicians’ affiliated accountable care organization (ACO), Triad Healthcare Network (THN), began using Pings™ to effectively monitor and manage their patients’ care events. Eagle Physicians soon saw the value that Pings provided to THN and implemented the platform to improve care across the entire Eagle Physicians network.

They began implementation with six of their primary care sites, as well as their pediatric site. Over the following weeks, the Bamboo Health team and the Centralized Quality Team facilitated in-person onboarding meetings with each Eagle Physicians site and team, which included practice administrators, clinical supervisors, front administrative supervisors and one pod member identified as a Pings “super user.” During these meetings, Bamboo Health provided each site with a demo to review the platform, as well as an overview of customized best practices and workflow recommendations.

Team of doctors and businessman using computer during the meeting in the office

Workflows

Currently, Eagle Physicians’ workflows for its hospitals are as follows:

1. At the beginning of each day, the Centralized Quality Team’s lead patient care advocate signs into Pings and views all patients who have been admitted to or discharged from a surrounding hospital within the last 24 hours.
2. The patient care advocate then uses the Pings export feature to pull a report on these care events. The report includes patient demographic information (age, sex, address, phone number, etc.), PCP/care team information, admission diagnosis, event location and date of event.
3. Care events are then divided among team members based on patient location. From here, patients are prioritized based on their level of complexity, with highly complex patients receiving the first outreach.
4. The Centralized Quality Team then calls recently-discharged patients and schedules appointments with their respective PCPs within 7 to 14 days. They also ensure that any other necessary appointments with specialists or home health services are in place. The Centralized Quality Team also uses this outreach to perform a complete medication reconciliation, troubleshoot any potential acute care events by answering questions or concerns and facilitate appointments with patients’ PCPs sooner if needed.
1. At the beginning of each day, the Centralized Quality Team’s lead patient care advocate signs into Pings and views all patients who have been admitted to or discharged from a surrounding hospital within the last 24 hours.
2. The patient care advocate then uses the Pings export feature to pull a report on these care events. The report includes patient demographic information (age, sex, address, phone number, etc.), PCP/care team information, admission diagnosis, event location and date of event.
3. Care events are then divided among team members based on patient location. From here, patients are prioritized based on their level of complexity, with highly complex patients receiving the first outreach.
4. The Centralized Quality Team then calls recently-discharged patients and schedules appointments with their respective PCPs within 7 to 14 days. They also ensure that any other necessary appointments with specialists or home health services are in place. The Centralized Quality Team also uses this outreach to perform a complete medication reconciliation, troubleshoot any potential acute care events by answering questions or concerns and facilitate appointments with patients’ PCPs sooner if needed.

Eagle Physicians rolled out a similar transitions of care process for its SNF patients. By being able to easily identify which patients are admitted to or discharged from SNFs through Pings, the Centralized Quality Team ensures that patients’ needs are met immediately following the care event, avoiding potential unnecessary acute care readmissions.

This outreach increases follow-up visits, improves overall TCM services and bolsters patient satisfaction.

Eagle Physicians’ Centralized Quality Team also monitors the Pings Platform throughout the day to view real-time events. The team can receive text and email notifications on new events and view them within the web application to ensure timely intervention and safer patient transitions.

The Centralized Quality Team, having only been using the platform for three months, is continually exploring the use of new features, such as the “High Utilizer” flag, which flags patients with three or more ED presentations in the last 60 days, as well as the Pings “Readmission Risk” flag, which flags patients with an inpatient discharge within the last 30 days. The team also hopes to start using the Pings solution’s data to monitor specific patient segments based on diagnoses; specifically, their chronic obstructive pulmonary disease (COPD) patients.

Patient Success Story

In one instance, the Centralized Quality Team received a call on a patient who had been discharged from a SNF. With limited information on the patient’s care event, the Centralized Quality Team searched for the patient within Pings, and determined that the patient’s PCP was within the Eagle Physicians network. The team called the PCP’s office, and discovered they had not been able to facilitate an office visit due to several failed attempts to get ahold of the patient or her family.

The Centralized Quality Team noted a unique phone number listed within Pings under the patient’s demographic information. Upon calling the new number, the team was able to reach the patient and learned that she had moved to live with a family member, obtained a new PCP and had sustained a C5 fracture. The team was able to gather the patient’s new information, while also providing support for the patient’s family members regarding where the patient could receive care.

By accessing Pings, the Centralized Quality Team was not only able to get in touch of the patient after numerous failed attempts, but was also able to determine discharge information and update the patient’s information—all of which are important for quality metric reporting and for the appropriate flow of patient records. Additionally, the team was able to provide support to the patient and her family and educate them on alternative settings where the patient could receive care for her injury.

Mature businessman and male doctor working on digital tablet at medical clinic.

The Results

Since implementing Pings, Eagle Physicians’ Centralized Quality Team has contacted 67% more patients for SNF transitions of care follow-ups.

Eagle Physicians has also experienced a 25% increase in the number of TCM visits that were billed for their THN patients.

About Eagles Physicians & Associates

Eagle Physicians & Associates is a private, physician-owned and physician-led multispecialty medical group in Greensboro, North Carolina. Eagle Physicians is the largest affiliated provider organization of Triad Healthcare Network ACO, consisting of six family practice sites, four specialty sites, one pediatric site, one walk-in clinic and one endoscopy center. Their core objective is to ensure long-term, consistent health and happiness for the patients they serve.

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.

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Prisma Health: Accessing Real-Time Insights in Clinical Workflows With PMP Gateway®

The Challenge

South Carolina mandates prescribers to query SCRIPTS, the state’s prescription drug monitoring program (PDMP) before writing or continuing a prescription for a controlled substance. South Carolina has been consistently among the 10 states with the highest opioid-related death rates. Recently, the state’s providers wrote 60.4 opioid prescriptions for every 100 persons, compared to the U.S. average of 46.7 prescriptions for every 100 persons.

Prisma Health, the largest not-for-profit health organization in South Carolina, recognized this challenge of managing high volumes of opioid prescriptions with complex workflows and sought a solution. Prior to integration, there was a separate login and querying process for SCRIPTS. “(Physicians) had to jump out to that site, look up information, review the patient report, and come back into workflow,” says Scottie Tooley, Manager of Ambulatory EMR Support at Prisma Health. “It required manual documentation of the fact that you had queried that database, in case we were ever audited. It required [additional] clicks and slowed them down.”

The Solution

Prisma Health partnered with Bamboo Health to provide over 1,000 clinicians with access to SCRIPTS through EHR workflow using PMP Gateway. PMP Gateway makes accessing data and analytics easy by integrating it directly in the clinical workflows of major EHRs. This interoperability allows clinicians to retrieve patients’ prescription histories in seconds and spend more face-to-face time with their patients.

PMP Gateway Empowers:

  • Integration of multi-state prescription drug monitoring program information
  • Simplified access to government-managed and regulated PDMP data directly within existing clinical workflows, reducing the number of clicks required for providers
  • Streamlined adherence to state regulations for monitoring controlled substance prescriptions
  • Quick and efficient results for querying patients’ prescription histories, freeing up valuable time for healthcare providers

“A combination of being able to check the PMP along with e-prescribing of controlled substances has definitely decreased the amount of fraud that we see. By far, the biggest satisfier is that I can click the link, I’ll see the report, I’m done. And not have to go and log into a different system. It makes providers more inclined to actually take the steps of checking the database, because it is not difficult.”

Dr. Jeffrey Gerac Chief Medical Information Officer at Prisma Health – Upstate

As Featured in Healthcare Innovation

In addition to leveraging Bamboo’s PMP Gateway solution, Prisma Health has expanded to utilize
several additional collaboration tools from Bamboo Health to improve care coordination. Read more about them in Healthcare Innovation: Prisma Health’s inVio Health Network Getting More Real-Time Patient Data

The Impact

That really helped to streamline the workflow to becoming much more of a one-click experience, for being able to review information, automate documentation and create a more compliant workforce.

Scottie Tooley Manager of Ambulatory EMR Support at Prisma Health
A female doctor with tablet talking to patient in bed in hospital MOBILE discharge summaries

The overall sense is that PMP Gateway is working well and is a very helpful tool. There’s been a tremendous push to change provider behavior on appropriate pain management, alternative pain management therapies, and non-opiates medications. So, having insight into everything the patient has received inside and outside of your organization, it is incredibly valuable at making an appropriate decision. We’ve definitely seen a very significant downward trend in total opiates prescribing over the last few years. Our providers can now easily query neighboring states’ PMP in workflow. That’s been a great help, too.

Dr. Jeffrey Gerac Chief Medical Information Officer at Prisma Health – Upstate

About Prisma Health

Prisma Health is a private nonprofit health company and the largest health care organization in South Carolina. The company has 29,309 team members, 18 acute and specialty hospitals, 2,827 licensed beds, 305 practice sites, and more than 5,400 employed and independent clinicians across its clinically integrated inVio Health Network. Along with this innovative network, Prisma Health serves almost 1.5 million unique patients annually in its 21-county market area that covers 50% of South Carolina.

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.

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University of Pittsburgh Medical Center Case Study

The Challenge

Pennsylvania requires providers to query the state’s prescription drug monitoring program (PDMP) database each time they prescribe an opioid or a benzodiazepine. But doing so required University of Pittsburgh Medical Center (UPMC) providers to exit the electronic health record (EHR) and log in to the state’s web-based PDMP portal. The process interrupted providers’ workflow and took valuable time away from face-to-face patient interactions. Because the process was cumbersome, it increased the risk that providers would not check PDMP databases and, in not doing so, unknowingly prescribe opioids the patient had already filled with prescriptions from other physicians. With more than 6,000 UPMC physicians conducting 6 to 7 million outpatient visits a year and an even greater number of telephone encounters annually, safely and effectively managing the many patients seeking pain relief — especially those managing chronic pain — was a priority.

Opioid Use in Pennsylvania

  • 14 Pennsylvanians die every day due to overdose.
  • 47 opioid prescriptions are given per 100 people across Pennsylvania, about the same as the national average.

The Solution

UPMC turned to Bamboo Health to integrate PDMP access into its Epic EHR using PMP Gateway. The integration enables providers to access PDMP data for patients in their workflow, including data from neighboring West Virginia, Ohio, Maryland and Delaware.

The results: providers saved time. Post-implementation, providers reported that a process that historically took minutes to check had been reduced to seconds. One pain clinic physician noted, “This has changed my life. The amount of time saved is unbelievable.”

Beyond time saved, the integration has supported important discussions with patients at the point of care. Dr. Anthony Fiorillo, Medical Director of Ambulatory Health Record at UPMC, and an internal medicine physician, often shows his patients their PDMP record during visits. “Our monitors are front and center with many patients, and this infuses an element of truth in the conversation about medications.”

“Trying to find PDMP data on a patient in the tri-state area using the old system was extremely difficult. It caused a lot of dissatisfaction and physician burnout. PMP Gateway now makes it much faster and easier to access data, allowing physicians to spend more time focused on their patients.”
– Dr. Kristian Feterik, eRecord Medical Director, Interoperability UPMC

“UPMC physicians have come to expect the Gateway-enabled PDMP access in the EHR as the norm for managing narcotics, and even those who may have been skeptical at first about the need for their particular practice have found it to be helpful in care discussions with patients.”

Dr. Anthony Fiorillo Medical Director of Ambulatory Health Record UPMC

About University Of Pittsburgh Medical Center

UPMC is a $21 billion world-renowned healthcare provider based in Pittsburgh and serving communities in Pennsylvania, West Virginia, New York and Ohio. The organization manages more than 40 academic, community and specialty hospitals and 700 doctors’ offices and outpatient sites.

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.

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Marcrom’s Pharmacy: Using PMP Gateway to Make Compliant Dispensing Fast and Easy

The Challenge

Tennessee pharmacists are required to check the Tennessee Controlled Substance Medication Database (CSMD) before dispensing controlled substances. In the rural city of Manchester, the pharmacists at Marcrom’s Pharmacy are familiar with local prescribers and have a history of safe prescribing practices. However, maintaining compliance was a time-consuming process that took each pharmacist nearly 20 minutes to complete every day. As a result, they had less time to spend one-on-one with patients.

The Solution

The Tennessee Department of Health contracted with Bamboo Health to integrate CSMD information into approved electronic health records (EHRs) and pharmacy management systems (PMSs) using Bamboo Health’s PMP Gateway® service in 2020. Before this transition, pharmacies and healthcare providers had to log in to the CSMD web portal to query patient data. The Gateway integration simplified the process by automating the request to the CSMD and making the patient report available in the pharmacist’s clinical workflow. This largely eliminated the need for Tennessee pharmacists and providers to navigate to the CSMD website, log in, and enter their patient’s information. Instead, controlled substance prescription records may now be obtained within the clinical workflow inside the EHR and PMS.

For Marcrom’s Pharmacy, this has meant more time for their pharmacists, less frustration with administrative tasks, and more potential to catch interstate doctor shopping and polypharmacy risks

The Impact

Two cheerful pharmacists working on medicines inventory at hospital pharmacy

From the pharmacy standpoint, Appriss Health (Bamboo Health) has done a great job! In a moment’s notice we can see everything we need-even interstate data. It populates everything so I can find patients much easier. I only have to push three buttons and I’m there! The integration was so seamless and easy for us, and the learning curve has been very, very simple.

Richard Randolph Pharm.D. at Marcrom’s Pharmacy
Pharmacist on their tablet accessing multi-state PMDP intelligence

It populates everything so I can find patients much easier. I only have to push three buttons and I’m there!

Richard Randolph Pharm.D. at Marcrom’s Pharmacy

At Marcrom’s Pharmacy, we have two to three pharmacists here every day, and they each check the system eight to ten times per day. With the new integration, we spend a quarter of the time versus having to go back and forth between standalone systems. Now, we only spend 15-20 seconds to get something done. Having this data integrated into our workflow has been fabulous!

Richard Randolph Pharm.D. at Marcrom’s Pharmacy

second average time to query the system

button access for critical patient context

time the pharmacy must check the system per day

About Marcrom’s Pharmacy

Marcrom’s Pharmacy is an independent pharmacy based in Manchester, TN. It has served thousands of patients since 1978 and is part of the statewide PMP Gateway integration that first occured in 2020.

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.

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Cedar View Rehabilitation & Healthcare Center Improves Continuity of Care With Pings™

The Challenge

Prior to implementing Pings™, Cedar View reviewed hospital discharge summaries upon patient admission and relied on patient or family memory to determine encounter history. External Care Managers would sometimes be able to help piece the history together, but consistently obtaining accurate information proved challenging. Once discharged, Cedar View had virtually no insight into that patient’s movement or other care encounters.

The Solution

Cedar View implemented Pings to obtain real-time insights with respect to patient movement throughout the continuum of care. Team members were trained on the Pings solution’s features and immediately noticed the improved care collaboration outcomes.

The staff commented on the tool’s ease of use and the benefits of having the helpdesk available for assistance on how to utilize a particular feature within the platform.

The team’s favorite Pings feature is the SMS notification option, as it makes the information available right at their fingertips. The team was able to adjust and personalize settings based on their notification preferences.

Workflows

The Cedar View team monitors Pings throughout the day, and especially prior to making a bed offer. If needed, Cedar View reaches out to the appropriate Care Manager to obtain further details on the patient. Upon admission, Cedar View contacts the Community Care Manager and uses Pings to validate the patient’s remaining Medicare days. Pings also allows team members to reach out to prior facilities or home care agencies from which their patients received care.

Currently, the Cedar View team using Pings consists of the facility’s Admissions Coordinator, External Clinical Screener, Facility Care Manager, Social Worker, Administrator and the Director of Nursing. These are the primary team members who receive the Pings and provide timely followup. As soon as a notification is received, the External Clinical Screener and Facility Care Manager are responsible for reviewing and acting on the information.

Patient Success Story

In one instance, an elderly, at-risk patient in the community had a history of frequent hospitalizations and had recently been discharged from Cedar View. Following a hospitalization, the patient denied home care agency entry into her home. Home care reported this incident to Cedar View. Cedar View was then able to monitor that patient in Pings and saw that she presented to the emergency department (ED) following a fall that left her with multiple fractures. Cedar View was able to intervene and welcome that patient back to their facility. Continuity of care provided the patient with a strong discharge plan, which may not have happened had the patient not returned to Cedar View. Pings allowed the Cedar View team to follow her discharge from home care and rehospitalization and allowed for a direct ED transfer, avoiding an unnecessary readmission.

The Impact

Since implementing Pings, Cedar View has seen an overall 3-5 day decrease in length of stay for their Medicare Advantage patients partly due to being able to stay in close contact with the external Care Manager through the contact information provided in Pings. This has allowed Cedar View to reach out right away and ensure that the right providers are involved and engaged with the patients admitted to the facility.

By receiving real-time information via Pings and communicating with external providers, Cedar View has seen an increase in total Medicare days and avoided unnecessary hospitalizations.

In its first year of Pings utilization, Cedar View reported a 6% decrease in readmissions as well as an increase in physician and medical team engagement in Cedar View’s interdisciplinary transition of care programming.

About Cedar View Rehabilitation & Healthcare Center

Cedar View Rehabilitation & Healthcare Center, located in Methuen, Massachusetts, is a skilled nursing facility (SNF) and a proud member of Marquis Health Services®. Cedar View is primarily focused on short term rehabilitation services, with Cardio Pulmonary and Orthopedic specialty programs. The facility has a comprehensive Spanish specialty program focused on meeting the needs of the Hispanic population within the community, as well as a transitional unit to ease patient transitions back into their community or long-term care.

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.

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Triad HealthCare Network (Cone Health) Avoided Unnecessary Inpatient Admissions and Saved Over $1.2M With Stories™

The Challenge

Triad HealthCare Network (THN), Cone Health’s provider-led accountable care organization (ACO) faced challenges with emergency department (ED) throughput, ensuring care management resources were able to operate at the top of their licenses and preventing unnecessary admissions and 30-day readmissions. Moreover, THN’s ED care managers and clinical social workers often had to spend critical time doing detective work to track down the non-Cone Health community providers (i.e., SNFs, home health agencies (HHAs) and provider organizations) with which a given patient has a relationship in order to properly coordinate their care.

THN prides themselves on their quality and commitment to exceptional patient care, with the patient’s well-being at the center of every decision they make. Due to the increasingly overwhelming ED environment, especially driven by the COVID-19 pandemic, a specific action plan needed to be put into motion to align with their goals and commitments to providing the utmost quality emergency care in a professional and compassionate environment.

The Solution

THN was the first North Carolina ACO to partner with Bamboo Health in 2017 to use Pings™, real-time notifications whenever patients experience care events across the continuum through admission, discharge and transfer (ADT) data. This enabled their providers to appropriately intervene and care for their NextGen ACO population of roughly 30K lives.

Due to the positive results realized from Pings, THN expanded its partnership over the next few years by increasing the number of patients monitored by Pings to roughly 90K lives as well as adding on two other Bamboo Health solutions: Spotlights™ and Route. Spotlights, real-time performance dashboards, help to power THN’s real-time analytics on skilled nursing facility (SNF) performance, 30-day readmissions and multi-visit patients (MVPs). Route is a compliance solution for the Centers for Medicare & Medicaid Services (CMS) mandated Interoperability and Patient Access Rule E-Notifications Condition of Participation (CoP).

While building momentum to improve patient outcomes, THN signed up for a pilot for their ED to use Stories™, Bamboo Health’s care transitions assistant that delivers relevant patient context within clinical workflows at the point of care. In the beginning of the pilot, three employees, a care manager and two nurses actively used the Stories platform to help understand where patients came from and why they were presenting to the ED. After THN team members began noticing the benefits of the solution, the organization soon requested that the pilot expand to its inpatient location.

Through Stories, ED and inpatient Transition of Care teams were able to:

  • Reduce readmissions and activate HHA providers by re-directing patients unnecessarily in the ED back home with a follow-up visit from their home care provider instead of admitting them to the hospital
  • Gain insight into recent SNF stays within the last 30 days, allowing them to re-direct patients back to the SNF they recently discharged from, helping increase continuity of care and prevent unnecessary admissions, all while avoiding the otherwise required 3-midnight stay to send the patient back to the SNF
  • Track high-utilizers and acute visit histories both in and out of Cone Health hospitals through the solution’s “high utilizer” and “readmission risk” flags in order to understand care utilization trends and diagnosis history
  • Easily connect with patients’ care teams through surfaced contact information, facilitating communication with community resources like ACO partners, federally qualified health centers (FQHC), and primary care physicians (PCP) in order to put together safe discharge or transfer plans as necessary

THN also decided to add new fields into care managers’ and clinical social workers’ ED Assessment pages in the Epic Electronic Health Record to better document the use, outcomes and return on investment of Stories. Such fields included transition of care time saved, whether a Ping was utilized in the transition of care assessment, whether an admission or readmission was diverted and which types of interventions were used in that diverted admission or readmission.

“Choosing Bamboo Health as our vendor to ensure compliance with the CMS E-Notifications CoP was an obvious choice for our team, as we’ve seen how critical these notifications are to improving care coordination, enhancing value-based care initiatives, and most importantly, transforming patient outcomes… By sharing this information about patient care encounters across provider settings, the Pings solution offers our clinical team increased IT operational efficiency to facilitate new levels of visibility and improved care.”

Valerie Leschber, MD Chief Medical Information Officer of Cone Health

The Results

The Stories pilot was a success. Roughly three months after going live, the ED care managers and clinical social workers saved on average 18-20 minutes per patient assessment. Moreover, they reported having more time to have meaningful conversations with patients because they didn’t have to spend time asking repetitive intake questions since that information was available in Stories. This benefit became increasingly valuable during the COVID-19 pandemic during which the ED was overwhelmed with cases. Saving time by not having to ask patients the same set of questions during their stay is paramount to providing the best possible care.

As a result of the successful pilot, THN decided to implement Stories in all of their campuses. This increased the number of employees using Stories from three to roughly 70, which includes case managers, nurses, clinical social workers and care guides in both inpatient and ambulatory settings.

The expanded use of Stories also improved care planning, coordination and management of their high-risk Medicaid population, helping Cone Health adhere to North Carolina’s Medicaid Managed Care contracts as a Tier 3 Advanced Medical Home.

Additionally, they monitor THN lives for their “Keeping Care Local” initiative. The initiative aims to increase continuity of care and network integrity by understanding trends in out-of-network care usage, ensuring timely follow-up by providers and coordinating with patients’ PCPs for increased care quality and patient engagement. For this population, Cone Health is leveraging Pings on a SmartRoster, which dynamically attributes any patient that discharges from a Cone Hospital to a roster in real time and then allows them to receive Pings on those patients for an allotment of time post-discharge.

A female doctor with tablet talking to patient in bed in hospital MOBILE discharge summaries

Since the Stories expansion in 2021, Cone Health has seen more astounding results due to Stories:

  • Saved 20-30 minutes on average per patient assessment since Stories provides prior care history, which aids in more knowledgeable conversations with patients as well as increased employee satisfaction because they have a tool that easily connects them with patients’ other care provider teams
  • Avoided 106 admissions from April 2021 – January 2022 by redirecting patients to previous or more appropriate post-acute care, amounting to over $1.2M. This doesn’t take into account potential 30-day readmissions avoided, so the savings could be even higher

 

“Our Transitions of Care teams have appreciated this expansion because it allows a patient’s care timeline to be captured without asking multiple, often duplicative, questions. We know the saved time in chart reviews equals more quality time with our patients, thus promoting the true value of healthcare to our patients and their care teams.”

—Rhonda Rumple, RN, MSN, BSN, CCM
Interim Vice President of Care Management Cone Health System / Triad HealthCare Network

THN saved 20-30 minutes on average per patient assessment

THN avoided 106 admissions, amounting to over $1.2M

About Triad HealthCare Network

Triad HealthCare Network (THN), located in Greensboro, North Carolina, is a provider-led Accountable Care Organization participating in the ACO Realizing Equity, Access, and Community Health (REACH) Model.

THN is sponsored by Cone Health and is governed and operated by a board of managers and a physician-led operating committee. We believe by working together, our network can provide the right care, at the right place, at the right time.

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.

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Pioneer Valley Accountable Care Reduces Costs and Improves Care Coordination With Pings™

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.