WellSky® recently hosted The New York Care Coordination Summit as part of their Thought Leadership Series — educational programs detailing how health systems and hospitals are tackling the most pressing issues in care coordination and post-acute care management today.
This summit was an opportunity for industry leaders to come together to discuss, innovate, and collaborate. Speakers included leaders from Mount Sinai Health System, NYC Health + Hospitals, VNS Health, and Landmark Health, and they talked about the critical challenges facing the modern healthcare landscape and the myriad of ways technology can be harnessed to achieve optimal patient and financial outcomes. They also shared how they’ve overcome challenges in value-based care and payment models, and attendees learned about developing proactive strategies for managing patient populations at scale and increasing data transparency to optimize care delivery and drive value across settings of care.
Here are some key takeaways from the event:
1. Putting patients first
New models of care and factors like diverse populations, technological advancements, and the evolving needs of patients are increasing the need for providers to evaluate their populations from cultural and socioeconomic standpoints. While the primary goal is to improve care and outcomes, improved patient engagement and retention, staff efficiency, and reductions in the cost of care are also potential benefits.
During the summit, leaders in New York shared that in the past, many population health programs were created with little insight into the communities they serve. A notable example of this was brought up by Landmark Health: In an effort to understand the root cause of why many patients were declining home visits in the beginning of the year, they leveraged WellSky data and insights to identify trends and learned that most of the patients declining visits around the start of the year were of Chinese heritage, a population that considers it bad luck to receive care in the home around the New Year. As a result of this discovery, Landmark Health trained staff and tailored care plans to better meet the diverse needs of these specific patients, ultimately leading to an increase in completed visits, better patient outcomes, and fewer hospital readmissions. With WellSky CarePort solutions, providers can now discover what their specific population needs are to help them develop more targeted programs and assign resources accordingly. Furthermore, it is now possible to closely follow these interventions in real time to ensure that they are working, and if not, leaders can make changes accordingly.
Summit participants all agreed that to shift toward health equity and more patient-centric care, providers need to revisit the idea of “traditional care” and how to find the best care options for individual patients and their unique beliefs, priorities, and social determinants of health.
2. Redesigning care
In today’s healthcare landscape, the shift towards value-based care is more crucial than ever. It’s not just about delivering care — it’s about delivering the right care, at the right time, and in the most cost-effective manner possible. Success in value-based care requires a strategic approach that prioritizes patient needs while optimizing resource utilization and keeping an eye on opportunities for innovation.
Currently, one of the ways VNS Health is adapting to the evolution of value-based care is by integrating behavioral health into their care management programs. This allows them to identify patients who may otherwise fall through the cracks (which is important, considering untreated behavioral health issues can balloon a patient’s total cost of care). By leveraging WellSky CarePort intelligence, VNS Health is able to more quickly identify patients with unmet behavioral health needs, influence care, and control spending.
In another example, with WellSky CarePort solutions, NYC Health + Hospitals now can communicate, coordinate, and facilitate care more effectively in a centralized location, leading to smoother care transitions and reduced length of stay. By harnessing the power of technology, healthcare providers can deliver more coordinated, personalized, and effective care to their patients.
3. The importance of post-acute care
Value-based payment models aim to reduce spending while improving quality and outcomes. So, to proactively manage the total cost of care, organizations must identify opportunities where they can reduce costs as patients move across the continuum of care. One of the most important areas in which an organization can reduce costs is in post-acute care.
Mount Sinai Health System has prioritized providing the right care at the right time by leveraging WellSky to facilitate real-time communication and coordination with post-acute partners. Without accurate, timely information about post-acute options and risks, acute providers like Mount Sinai lack the visibility to make timely and informed decisions for their patients. But by prioritizing their network of high-performing providers and utilizing real-time emergency department (ED) utilization and risk-adjustment data from WellSky CarePort solutions, Mount Sinai was able to more heavily influence care, which lead to reduced lengths of stay and improved patient outcomes.
Additionally, the real-time alerts in WellSky CarePort solutions have provided Landmark Health with more opportunities to engage with patients as soon as they leave acute care settings for home, improving outcomes and reducing readmissions. The sooner a post-discharge visit happens, the more likely a patient will stay out of the hospital. With WellSky, Landmark has been able to make more post-discharge visits happen and improve their post-discharge visit metric from 50% to 80%.
4. Measuring success in value-based care
Panel participants shared that one of the biggest challenges in measuring success in value-based care is accessing meaningful and timely data. While claims data can be a useful tool, it can be out of date and have significant gaps (since some care, such as ED utilization, is not authorized). Real-time performance data provides organizations with the opportunity to make changes and course-correct earlier to achieve better outcomes and savings.
WellSky CarePort solutions integrate data from multiple sources, including electronic health records (EHRs), claims data, and other healthcare systems, to provide more comprehensive insights into patient care patterns and outcomes. For example, by leveraging the WellSky advanced analytics and reporting capabilities, VNS Health is able to identify high-risk patients, monitor performance metrics, and optimize care delivery strategies to align with value-based care objectives. With WellSky CarePort solutions, risk-bearing entities gain real-time visibility into patient journeys, which can help improve patient care, care transitions, and outcomes.
5. Staffing
Widespread staffing challenges, which include a shortage of qualified personnel, high turnover rates, and increased demand for healthcare services, continue to plague the healthcare industry. These challenges are often exacerbated by factors such as evolving healthcare needs, long hours, high stress, and the emotional toll associated with healthcare work—all contributing to staff burnout. The competition for talent further intensifies the issues as healthcare systems strive to meet growing demands for care while ensuring quality and safety.
Panelists agreed that to address these challenges, healthcare organizations must learn to do more with less. One of the most effective ways to achieve this is with the help of innovative technology that can help maximize efficiency and streamline care. With WellSky, providers gain enhanced insights into higher risk patients and the ability to quickly identify patients who need an intervention or additional services while reducing administrative burdens.
In conclusion
The New York Care Coordination Summit provided an extraordinary and powerful opportunity for leaders to come together and collaborate in ways that not only improve patient care but also address challenges and streamline their processes in a fiscally responsible and efficient way.
Providers who use the WellSky suite of CarePort solutions can decrease readmissions, leverage real-time metrics to compare post-acute performance, streamline care for patients, identify gaps in care and opportunities for improvement, and improve long-term financial return.
Learn more about how WellSky® can empower your providers to meet the most pressing challenges in care coordination and post-acute care.
