Collaborative Case Management | COVID-19 Special Issue

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COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG

Healthcare Leaders Share Valuable Learnings from COVID-19 to Improve Care Transitions

By B.J. Boyle, Vice President and GM, Post-Acute Insights at PointClickCare

Senior living, long-term, and post-acute care facilities, among the hardest hit by the COVID-19 crisis, are reexamining care transitions to better protect their patients, manage risk, and prepare for challenges that may lie ahead.

To help, leading providers and payors in healthcare share their most valuable takeaways and the lessons they’ve learned during the COVID-19 pandemic. Together, we can leverage experiences and newfound knowledge to navigate this challenging time and help to create our new normal.

Here leaders share four valuable lessons impacting care transitions and patient experience:

Understand your patient population to build an effective preparedness plan.

Skelly Wingard, Mid-Atlantic Vice President, Continuum of Care at Kaiser Permanente, advises organizations to create or improve their preparedness plan by addressing staffing, support and supplies, and cautions that effectiveness depends on a thorough knowledge of patient populations.

When they are not physically seeing their doctor or case manager, what is the customer experience?

“We need chart level data to identify highrisk patients and the resources they need, and an understanding of our partners so we know who has resources—and a sophisticated model—to help,” says Wingard. “The more you understand that, the more equipped you are to react and intervene when tragedy strikes.”

She advises organizations to include all constituents—key administrators, associations, departments of public health, local and county health services, health plans, med groups, and others.

“Your plan needs to dictate how these entities work together and align to be effective and efficient,” she says.

Knock down silos. Collaboration is key to patient experience.

Collaboration and communication between hospital systems and post-acute care systems is critical to managing a crisis, addressing hot spots and providing a better patient experience.

“COVID made us think about the importance of the patient experience and ensuring team members at the skilled nursing facilities have as much time as possible to spend with patients to care for them,” said Lori Baker, Director, Preferred Provider Post Acute Network at TriHealth. “Both hospitals and skilled nursing facilities can get overwhelmed with volume, rapidly and repeatedly cycling patients from hospital to nursing facilities. It’s important to minimize the amount of time spent on manually entering patient data to enable team members to spend time with patients. Preparation and electronic data exchange allow us to better collaborate without post-acute providers and ensure a more seamless transition.”

Successful care transitions depend on data.

Many organizations have developed dashboards to gather, analyze, and share COVID-19 data, leveraging it to make more informed decisions.

Dr. Tere Koenig, an internist geriatrician and Executive Vice President and Chief Medical Officer for Medical Mutual, says her team quickly created a COVID dashboard looking at who had been admitted with COVID or potential COVID and who needed high level care, such as ICU, so they could understand capacity needs and adjust resources, as well as provide staterequired weekly updates on SNF cases.

Similar dashboards also helped teams at Kaiser and TriHealth, who assessed patient populations and testing status to

proactively triage patients, coordinate care, and manage transitions.

“More transitions mean higher risk, including risks to paramedics, nurses and other care providers patients interact with during transit,” says Wingard. “Data helped us use transitions sparingly and only when appropriate.”

Patient experience has, perhaps, never been more important.

A marked increase in televisits and a change in patients’ expectations of when and how often they need to seek care means providers may be seeing less of their patients. Koenig estimates a 30-40 percent drop in unnecessary visits during the crisis—likely tied to fear of catching COVID-19, the elimination of elective procedures during quarantine periods, and limited availability—and predicts the trend will continue.

“When they are not physically seeing their doctor or case manager, what is the customer experience?” says Wingard. “We’ve become successful in case managing patients in a remote way, but we need to be mindful of what that feels like for a patient over a longer term.”

It’s likely that patient experience will become an important component of infectious disease planning playbooks. “Some of our dashboards and patient tracking methodologies will be scalable for anything,” says Baker. “We now know how to track our data.”

LOOKING AHEAD

Though still in the beginning stages of managing this pandemic, we can better prepare for and respond to challenges as they arise by learning from the lessons we’re sharing along the way.

To read the full interview, visit www. pointclickcare.com/ACMA.

ABOUT THE AUTHOR

B.J. Boyle is the Vice President and GM of Post-Acute Insights at PointClickCare. He can be reached at BJ.Boyle@pointclickcare.com.

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