Recently, Samir D’Sa, General Manager of Landmark Health’s New York City office joined CarePort CEO and founder Lissy Hu, WellSky CEO Bill Miller, and WellSky CMO Shoma Sarkar Thomas on a panel at Home Health Care News’ Capital + Strategy Summit.
Landmark Health, a CarePort customer, is a risk-based provider group that offers in-home primary and urgent medical care to chronically ill Medicare Advantage patients. Landmark uses our platform to streamline and automate the transition from acute to post-acute care. “Landmark Health has a DNA of building technology solutions in-house… but we’re also able to plug in various critical assets, and I think CarePort is definitely one of them in the New York City market,” said Samir D’Sa. “What CarePort does for us is, is it alerts us when our patients leave the hospital in real-time.” Historically, the transition from acute to post-acute care was an incredibly manual process, in which home health care managers had to continuously call hospital care managers or discharge planners for an update regarding patient status. There was also a heavy reliance on faxing and phone calls, and printed lists of providers handed to patients with minimal guidance regarding provider quality and services. Once patients were discharged from the hospital, they went into a “black hole” of post-acute care, in which providers had no way to track their care or outcomes.
With CarePort’s real-time discharge notifications, Landmark Health is able to immediately schedule a post-discharge visit – which includes medication reconciliation and a review of treatment plans with the patient. Landmark Health tries to conduct its post-discharge visits within 72 hours of patient discharges, and real-time information is critical to do so; claims data is far too delayed. This longitudinal care is critical, particularly for patients that have multiple transitions in a single episode of care. For example, a patient may transition from the hospital to a skilled nursing facility, and then to home health care. In this case, it is critical for the home health provider to have visibility into a patient’s discharge from the SNF to avoid potential gaps in care.
Care coordination initiatives, and care transition technologies like CarePort, power improved outcomes for patients. Acute and post-acute providers – including skilled nursing facilities and home health care – are all stakeholders in a patient’s care, and technology is a lever that allows disparate providers to connect and communicate in real-time, sharing critical information at relevant points of a patient’s journey across the continuum. As Lissy noted during the panel, “As I think about where we’ve been and where we’re going, I believe there will be more and more focus on care transitions; not only the care transitions that occur from the hospital to the first level of care, however, but also all of the other care transitions that patients go through as they move through the care continuum.”
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