Transitions of Care Hub

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Welcome to the CarePort Health COVID-19 Transitions of Care (“TOC”) Hub. Here we will share current learnings, latest trends, and best practices for safe and effective transitions for COVID-19 patients. Given the rapidly evolving nature of the outbreak, the learnings and best practices will be updated frequently based on what we’re learning from the 1,000 hospitals and 110,000 post-acute providers that are connected on our platform.

Hospitals that use our platform across the US send 18 million referrals annually to skilled nursing, home health, hospice, long-term acute and acute rehabilitation, accounting for nearly 40% of all acute to post-acute transitions nationally. Given that CarePort customers are on the front lines of the pandemic, the TOC Hub aims to disseminate critical lessons learned in real time.

We are providing free access to the TOC hub to help hospitals and post-acute providers understand how to navigate care transitions during the pandemic. 

Best Practices

Many hospitals are having difficulty discharging COVID-19 patients to post-acute providers. To avoid these bottlenecks, hospitals should work to identify post-acute providers that are accepting or are currently caring for COVID-19 patients. Within CarePort for example, post-acute providers are updating their capacity to accept COVID-19 patients on a daily basis, allowing case managers to filter down to only those providers that can accept COVID-19 patients.

When should a COVID-19 patient be transferred to post-acute? What care protocols should the nursing home or home health agency follow? What happens if a COVID-19 patient decompensates in a post-acute setting? Hospitals are creating transitions of care protocols for COVID-19 patients to ensure a successful discharge. As part of that, hospital customers are building upon their post-acute partnerships and working with post-acute providers on discharge and placement criteria, post-acute care plans, and communication protocols. For example, CarePort is working with its hospital clients to notify post-acute providers in their immediate geographic regions regarding COVID-19 protocols, best practices and the status of patients undergoing testing to reduce time spent by individuals completing this manually. CarePort is also providing clients with a COVID-19 assessment created by one of our client partners for patients referred to nursing homes. Nursing homes can use this information to easily identify if they are able to accept the patient.

Hospitals may be aware of COVID-19 diagnoses at their own facilities, but patients though often seek care at outside hospitals, and even across state lines. Hospitals in a region are working together to share information on COVID-19 patients who may be seeking care from multiple health systems. For example, hospitals are activating real-time notifications for newly diagnosed COVID-19 patients. Hospitals are using CarePort to automatically alert providers who may have had an encounter with the patient in an ED or nursing home prior to diagnosis. Real-time alerts are also being sent to the primary care physician so that they can help with follow-up care.

Many hospitals and nursing homes at this time are restricting visitor access. As part of the conditions of participation for discharge planning, hospitals must share post-acute care options with patients and help them select a post-acute provider. Without the ability to tour facilities or a family member at the hospital to help, hospitals must adapt their discharge planning processes. For example, hospitals are using CarePort to share nursing home options with families via text message or email. Family members, who otherwise would be on-site, can see an interactive guide that includes virtual tours and pictures and help their loved ones select the right post-acute provider.

Post-acute providers are isolating COVID-19 patients in specific wings or facilities and as such are adapting their intake protocols. For example, post-acute providers are working with CarePort to direct referrals to only those facilities within a post-acute system that are able to accept COVID-19 positive patients.

State Guidance on Post-Acute protocols

We encourage each state to follow the guidance being issued by their Department of Public Health in regards to hospital discharge and post-acute admission protocols. We’ll be updating various protocols here as they are made available. 


CarePort On-Demand Webinar: COVID-19 Hospitalization Insights

CarePort On-Demand Webinar: Digesting the Data: New CMS COVID-19 Nursing Home Numbers

Free CarePort Guide 90-Day Trial: To help hospitals manage the challenges of finding post-acute care – for both COVID-19 patients and patients with post-acute needs – for a limited time CarePort is offering a lightweight version of CarePort Guide. CarePort Guide can help alleviate the difficulty of finding appropriate post-acute care during the COVID-19 crisis.

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