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PPCP and CarePort: complex care management

CarePort recently hosted a thought leadership webinar with Preferred Primary Care Providers (PPCP), the largest independent primary care practice in Western Pennsylvania. Prior to implementing CarePort, PPCP struggled to understand real-time events emergency department (ED) visits, readmissions, and referral patterns from hospitals and post-acute providers, and relied upon data from various sources – including ADT feeds, electronic medical records (EMRs), claims data, and patient lists – which was a resource intensive process, inefficient, delayed, and often resulted in incomplete information. PPCP implemented CarePort Connect in January 2021 and quickly identified several use cases in which CarePort’s real-time data could help support the organization’s business model, and help provide enhanced care and outcomes for their patient population.

In our previous blog post, we shared how CarePort helps PPCP with active daily management. In this blog post, we’ll dive into PPCP’s use of the CarePort platform for their complex care management (CCM) program.

PPCP’s CCM team leverages CarePort Connect in the following ways:

Transitions of care: The team monitors inpatient admissions and ED visits, and also obtains a snapshot of a patient’s utilization history and referral patterns – all in real-time in CarePort. The team uses CarePort to identify those who need post-discharge follow-ups to ensure patients understand their discharge instructions, have scheduled follow-up visits with their primary care providers (PCPs), and to assess whether home health care has been initiated, if applicable.

CCM program referrals: PPCP reviews CarePort’s high-ED utilizer and readmissions flags as part of the active daily management huddle to screen for patients who could potentially benefit from the CCM program. CarePort is also used to identify patients for disease-specific programs based on discharge diagnosis. 

Cross-continuum patient monitoring: Through CarePort, PPCP care managers follow patients enrolled in the CCM program, equipping them with real-time notifications when patients have utilized the ED, hospital, skilled nursing facility (SNF), or home health from one or more of these care settings. Leveraging this real-time information, care managers can conduct timely follow-ups and interventions – whether after an ED or SNF discharge. Providing patient follow-up at the right time helps PPCP achieve improved patient experience and outcomes.

During the webinar, PPCP shared an example of how cross-continuum collaboration, transparency, and real-time information leads to improved care coordination and patient outcomes: A home health provider identified a PPCP patient who wasn’t well-managed at home and was at risk for readmission. The home health provider coordinated with a CCM care manager to discuss the need for a higher level of care. The at-risk patient’s home health provider, care manager, medical social worker, and PCP then worked collaboratively to coordinate the patient’s direct admission to a SNF. Once a facility was identified, the patient’s care team made two attempts to contact the patient, who didn’t answer either phone call. PPCP then searched for the patient’s status in CarePort and could see that the patient had presented to the ED within the last 15 minutes. Leveraging this information, the social worker contacted the ED; together, the providers worked together to place the patient with a preferred SNF.

Patient engagement: Patients are often difficult to reach, particularly when not engaged with their PCPs. As these hard-to-reach patients access the healthcare system and utilize one of PPCP’s preferred providers, CarePort allows PCP to reengage with the patient, address barriers, and provide additional support services.

For example, PPCP encountered a very difficult case in which a patient was in and out of the acute care hospital and SNF. While determining how to best manage this patient’s care, the PCP lost sight of the patient’s location and status. Within the CarePort platform, PPCP could see that the patient had been admitted to a non-preferred SNF. With this visibility, PPCP quickly reengaged with the patient – through outreach to the SNF and the patient’s spouse – to develop a plan of care that would help mitigate utilization. Based on the patient’s medical condition, the patient was deemed hospice appropriate and was referred for hospice consult. In this circumstance, PPCP coordinated with the hospice provider, SNF, and the patient’s spouse to intervene and provide the patient the appropriate level of care at the right time.

PPCP continues to uncover opportunities to make use of the information received in CarePort to enhance patient operations, quality of care, patient experience, and provider partnerships.

Our next blog post will share how PPCP leverages CarePort for post-acute care workflows. In the meantime, read our latest blog post that discusses how CarePort helps PPCP through real-time patient management. You can also watch the entire PPCP webinar on-demand or contact us with any questions.

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