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Care Across the Continuum: Finding the Right Post-Acute and Community-Based Services for Patients

In today’s evolving healthcare landscape, higher acuity patients are increasingly being transitioned from hospitals to facilities and the home. As a result, discharged patients have more care and community resource needs, and case managers have to arrange multiple types of after care. To help patients recover quicker and more completely — whether in a facility or in the community — providers should incorporate all aspects of patient health as part of their care journey.

Connecting patients to both medical and non-medical services helps ensure continuity of care, improve patient health, reduce readmissions, and decrease healthcare costs. And, with the rise of value-based care models and risk-based contracting, healthcare organizations are further incentivized to ensure patients receive the appropriate care.

For care coordination teams, easy-to-use systems like CarePort can help providers identify these critical medical and non-medical services and generate referrals within the same workflow, without the need for multiple tools or databases. Providers on the CarePort platform can search the CarePort network for a wide range of services and easily arrange care for patients as they prepare to leave the facility. In addition to sending common post-acute referrals to skilled nursing facilities (SNFs), home health care, and long-term care, organizations can also refer patients to other types of providers from the same platform, such as:

  • Physical therapy
  • Transportation
  • Behavioral health
  • Meal providers
  • Medication management
  • Other home- and community-based services


CarePort continues to broaden and enhance its referral network to achieve better, more coordinated care across the continuum. In 2021, CarePort added over 13,000 home- and community-based providers to the CarePort network. Now, referral partners can support complicated discharges by searching and connecting to over 130,000 providers on the CarePort database, all within one workflow. And, post-acute and community-based organizations can increase visibility within CarePort to help care managers select appropriate, high-quality care and achieve better patient outcomes.

Here are some examples of the diverse range of care organizations that providers can access through CarePort, as well as information on why it’s important for referral partners to include these services in their networks.


Behavioral health

The COVID-19 pandemic highlighted the importance of easier access to behavioral and mental health care. Although the demand for behavioral health services was rising prior to the COVID-19 pandemic, 52 percent of behavioral health organizations saw an increase in demand for services in 2020, according to a survey from the National Council for Mental Wellbeing. Behavioral health continues to play an increasing role in whole-person care initiatives. For example, the Department of Health and Human Services (HHS) recently introduced a $15 million funding grant to strengthen critical behavioral health services in nursing homes and other long-term care facilities.


Physical therapy

Patient preferences have shifted to receiving care at home — a trend accelerated by the pandemic. Patients who might otherwise have been discharged to a SNF are now going home and requiring additional services to successfully recover. The pandemic reshaped care delivery for physical therapy, forcing providers to adapt and offer services outside of facilities. Now, case managers can use CarePort to find providers who offer outpatient physical therapy services at home.

CarePort network: Physical therapy provider spotlight

Luna Health

Luna is the leading in-home physical therapy platform, offering one-on-one personalized care at home that is covered by insurance. By shifting treatment from the clinic to the home, Luna is reinventing outpatient physical therapy and improving convenience, access, safety, and adherence.


Durable medical equipment (DME)

The U.S. population as a whole is getting older, and with that, chronic disease is expected. Those individuals are now projected to live longer than ever before, and as a result, there will be an increase in disability and the need for durable medical equipment (DME) and other adaptive devices. DME can help support activities of daily living (ADL) and promote an individual’s overall wellbeing and independence.


Telehealth services

Home telehealth services have become increasingly popular in recent years, with the pandemic contributing to an accelerated adoption of telehealth services. For patients transitioning between levels of care, providers can utilize remote patient monitoring services to observe patients in real-time and quickly address any changes in a patient’s health status.

CarePort network: Home telehealth provider spotlight

Vis-à-vis Health 

Vis-à-vis Health is a complete at home telehealth solution for patients transitioning between levels of care. Their clinical staff remotely monitor patients’ daily vitals and trends, ensuring timely care coordination, and preventing avoidable hospitalizations. Vis-à-vis Health’s remote patient monitoring service also offers face to face visits between patients, families, and physicians. Vis-à-vis Health partners with various home care agencies, primary care physicians, DME vendors, at-home services providers, and other organizations.


Memory care and senior care services

Memory care services are specialized for individuals living with Alzheimer’s and other forms of dementia; facilities are uniquely designed to cater to the specific cognitive needs of patients with memory loss. In addition to memory care services, case managers can use CarePort to find providers who offer a range of senior care services, including independent living and assisted living.


Addressing a patient’s medical and non-medical needs at discharge is vital to meeting all aspects of a patient’s health requirements. And, cross-continuum collaboration, communication, and transparency is critical to streamlining care transitions, managing patient outcomes, and improving value-based care.

CarePort is connecting care teams across the entire continuum to improve patient care and care transitions. Learn more about how CarePort helps post-acute providers and community-based organizations increase visibility to referral partners and enables them to receive, review, and respond to referrals — all on one platform.

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