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Bridging the Gap Between Ambulatory Providers and Home or Community Resources

Hospitals and health systems are increasingly turning to ambulatory care providers – which include physician offices, offices for other health care professionals, hospital outpatient departments, ambulatory surgical centers, specialty clinics or centers (for example, dialysis or infusion), and urgent care clinics – to support patient care outside the four walls of a hospital. However, ambulatory providers often lack critical information regarding a patient’s care in other settings, which make care coordination efforts challenging. To ensure quality patient care and achieve improved outcomes, ambulatory providers require the capabilities to support whole person care, and increase efficiencies through home and community-based electronic referral processes​.

Home-based care

The past fifteen months have brought a marked shift in care delivery at the acute and post-acute level. Specifically, the pandemic spurred the shift to home health rather than post-acute care in institutional settings such as skilled nursing facilities (SNFs) and nursing homes. CarePort data shows that home health continues to expand its post-acute market share, currently comprising 60% of referrals, whereas prior to the pandemic there was an even split between referrals to home health and SNFs. As care is increasingly delivered outside of the four walls of a SNF or nursing home – and instead within a patient’s own home – it’s more critical than ever before that ambulatory providers can efficiently refer patients to home health care, and also gain enhanced visibility into a patient’s care.

Community-based care

Ambulatory providers are largely responsible for driving community-based initiatives, including social determinants of health (SDOH) initiatives. SDOH – including housing, food security, and economic stability — can have a tremendous impact on healthcare outcomes and costs. Approximately 80% of contributors to health outcomes are actually non-medical, and can instead be attributed to environment, behavior, and genetics, and more than one-quarter (28%) of Americans have endured health risks stemming from unmet social needs. Intervening and addressing a patient’s unmet SDOH needs can prevent unnecessary hospitalizations, readmissions, or emergency department visits, as well as other poor clinical patient outcomes. However, many ambulatory providers – such as physician practices – lack the appropriate technologies to efficiently refer patients to community-based organizations (CBOs) and then monitor the patient to ensure follow up.

CarePort in the ambulatory setting

CarePort equips physician practices and other ambulatory providers with the capabilities to coordinate care with home and community-based services, as well as track patients who receive care in the hospital or in the community.

  • Electronic referrals: CarePort enables electronic referrals to home and community-based care providers such as home health, durable medical equipment, transportation, food insecurity services, and physical therapy, among others – eliminating the need for faxes or phone calls. Currently, home and community-based referrals are largely executed through faxes and phone calls, which is highly inefficient for office staff.
  • “Closed loop” handoffs: Additionally, many ambulatory providers lack a means to “close the loop” on referrals to ensure patients are receiving the intended products or services referred by the physician. Leveraging the CarePort platform, ambulatory providers can search a national database of providers, facilitate an electronic referral, maintain two-way communication throughout the referral process and “close the loop,” ensuring that patients’ needs are being met within their home or in the community.

Many ambulatory providers lack the adequate technologies to track and monitor patients across the continuum and into home- or community-based care, but this insight is imperative to achieving better care transitions, improved quality of care, and lower cost of care. CarePort enables ambulatory providers to bridge the gap between patients and home or community resources so that patients don’t fall through the cracks – while also streamlining processes for staff, and ultimately resulting in more favorable patient outcomes and potentially lower cost of care.

For more information regarding the CarePort platform for ambulatory providers, please contact us.

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