CarePort® powered by WellSky® recently hosted The Chicago Care Coordination Summit as part of their Thought Leadership Series, which features educational programs detailing how health systems and hospitals are tackling the most pressing issues in care coordination and post-acute care management. The Chicago Summit was a rare opportunity for thought leaders in the Chicagoland area to come together for a powerful day full of discussion, innovation, and collaboration. Speakers from Northwestern Medicine, Rush University Medical Center, and University of Chicago Medicine shared their experiences and what they have learned. Below, we share key themes and takeaways from the event.
Patient needs come first
New models of care and factors like aging populations, technological advancements, and the evolving needs of patients are increasing the need for providers to evaluate population health needs. While the primary goal is to improve care and outcomes, providers can also benefit through improved patient satisfaction scores, higher staff productivity and morale, and reductions in the overall cost of care.
Leaders in Chicago shared that in the past many population health programs were created with little insight into the community. With the advent of solutions like CarePort, hospitals can now see what their population needs to develop programs and assign resources accordingly. Furthermore, it is now possible to closely follow these interventions in real-time to ensure that they are working or make changes as they go.
A notable example of this is how Northwestern Medicine is putting patient needs first by improving post-acute care, strengthening their post-acute networks, and shifting to an overall population health strategy. While many organizations are moving in this direction, what makes Northwestern Medicine stand out was how they focused on quality over cost-cutting. They focused on innovative care models for appropriate post-acute utilization and RN support across the continuum to ensure patients were recovering appropriately at each point in their journey. Leveraging CarePort technology, Northwestern Medicine was able to begin monitoring patients during their post-acute stay; a key functionality for programmatic success.
The shift to home-based care
Spurred by the COVID-19 pandemic, the industry has experienced a marked shift to home health care and has an opportunity to rethink home-based care. Virtual care is on the rise, more patients are reevaluating how and where they want to receive care, and innovative technologies and capabilities are making care delivery and coordination easier and more efficient for both patients and providers. Home-based care could help improve the quality of care and patient experience by providing patients with care in the comfort of their own homes and potentially reducing adverse health events.
Summit participants agreed that to meet this shift, providers need to rethink the idea of traditional care and how to find the best option for an individual patient and their needs. In some cases, a skilled nursing or home health facility might not be the best option for a patient whose care needs can be met by another provider or in a different care setting.
The evolution of discharge planning
The transition from acute to post-acute and home settings can be challenging for many reasons. Discharge plans can be complicated and often lack standardization. Patients can be overwhelmed by the onslaught of options, new medications, and follow-up instructions like scheduling appointments. Additionally, higher acuity patients are often more difficult to place due to their more complicated needs. While discharge planning can be challenging, it is one of the main factors relating to the quality of a hospital. Efficient discharge planning improves the quality of care and reduces hospital readmission rates.
During a panel discussion around discharge planning, Chicago-area leaders shared how they are addressing this challenge. For example, the acute team at University of Chicago Medicine continues to assist with discharge planning even after a patient gets to a PAC facility. Another strategy they found beneficial was to have weekly meetings with a wound care specialist from an LTACH environment to meet with one of their medical directors around patients who may be eligible. That helped develop trust and optimize transition timing.
With care shifting to the home, tracking patients after they leave the hospital and reducing readmissions is more important than ever. Readmissions are costly to hospitals, patients, and payers, lead to poor outcomes, and reduce patient satisfaction. So, how are health systems working to reduce readmissions?
Jon Chapman, the Executive Director of Care Coordination at the University of Chicago shared that they are partnering with managed care organizations and insurance companies since they engage with in-network patients. Their ambulatory coordination team watches for acuity, provides advance care planning services, and guides patients to palliative and hospice care when appropriate. They also work with home health to identify patients to be repatriated back to the skilled nursing facility instead of the emergency department.
Kathleen Egan, Director of Care Transitions at Rush University Medical Center, says they are using an independent unit model that allows for more one-on-one time with patients and dedicated NPs who oversee every aspect of patient care. Some providers also use CarePort Care Management to put a discharge plan in place at the start of each patient’s stay. When accomplished, they have seen fewer readmissions and better outcomes.
It is no secret that the COVID-19 pandemic brought about widespread labor shortages including an immensely challenging healthcare staffing shortage. The long hours and stress of the pandemic also led to mental health issues and provider burnout. Competition for high-quality staff has never been higher.
To address these challenges, organizations are shifting the way they interview and onboard new staff, providing more training and certification opportunities, and improving their benefit packages. Organizations are also increasing the availability of telehealth and the usage of patient cohorting and technology like CarePort to help to maximize efficiency and streamline care.
“To get all these leaders from the most premier healthcare organizations in the area, in one room, collaborating and brainstorming ways to improve patient care was a powerful thing to be a part of.”
– Roy Surges, Sr. Regional Account Executive at CarePort®, powered by WellSky®
The Chicago Care Coordination Summit provided an extraordinary and powerful opportunity for leaders to come together and collaborate on ways to not only improve patient care but to also address challenges and streamline their processes in a fiscally responsible and efficient way.
Providers that use CarePort solutions including Care Management, Connect and Insight 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 CarePort®, powered by WellSky® can help your organization.