In CarePort’s thought leadership webinar with Preferred Primary Care Providers (PPCP), the largest independent primary care practice in Western Pennsylvania shared how it struggled to understand real-time events such emergency department (ED) visits, readmissions, and referral patterns from hospitals and post-acute providers because of a reliance on delayed and often incomplete information from electronic medical records (EMRs), claims data, and patient lists. Upon implementing CarePort Connect in January 2021, PPCP quickly identified several use cases in which CarePort’s real-time data could support the organization’s business model, and achieve enhanced care and outcomes for their patient population.
In our previous blog posts we shared how CarePort helps PPCP with active daily management and in their complex care management (CCM) program. In this blog, we detail how PPCP leverages the CarePort platform for their post-acute care workflows. Post-acute care – and ensuring patients receive care from high-quality skilled nursing facilities (SNFs) – is a primary focus for PPCP and is foundational to its model as a physician group that manages global risk.
In-network provider initiative
PPCP has dedicated physicians who are responsible for staffing certain SNFs. In evaluating SNF provider performance, PPCP validated that patients treated by PPCP-staffed facilities experienced better outcomes than those in non-staffed facilities. Meeting with hospital partners, PPCP leveraged these positive outcomes to work collaboratively and establish an initiative for in-network providers. As they were working with their hospital partners, PPCP wanted to evaluate referral patterns amongst in- and out-of-network SNFs. PPCP is able to do this with CarePort, which allows their team to review referral patterns in near real-time – as well as share this information with partners on a monthly basis. Leveraging the CarePort platform, PPCP has established more transparency with its hospital partners in evaluating how the initiative is performing, and continuously evolve the program to ensure positive outcomes.
Tracking discharge trends
CarePort allows PPCP to easily follow patients throughout their journey of care, seamlessly identify which hospitals most frequently refer to out-of-network providers, and gain visibility into the non-preferred facilities to which a hospital sends the highest volume of patients. Additionally, CarePort empowers PPCP to share these insights with health plan partners – creating a continuous line of communication and collaboration, and ensuring all relevant parties are aligned on performance outcomes.
PPCP also wanted to ensure that their patients were assigned to PPCP physicians rounding in facilities. As PPCP reviewed referral trends from CarePort, they quickly realized that 40% of their patients weren’t assigned to a PPCP physician in the facility. Recognizing it may not always be apparent who the attributed primary care provider is when the patient is admitted to a SNF, PPCP addressed the issue in their active daily management (ADM) huddle and worked with SNF partners to implement a process to ensure that PPCP patients were followed by a PPCP physician within each facility. Equipped with enhanced visibility and real-time data through the CarePort platform, PPCP has been able to reach out to facilities on a daily basis and ensure appropriate physician assignment, which has had an immediate impact on patient outcomes. Now, nearly 100% of PPCP patients are assigned to PPCP physicians within in-network SNFs – critical to ensuring their patients receive the best care.
SNF network management dashboard
PPCP also utilizes the Market Analytics page within CarePort Insight to review SNF Star Ratings, as well as key performance indicators across the entire spectrum of facilities – comparing PPCP patients to the entire SNF network within the CarePort platform. Through real-time SNF management, PPCP is seeing an increase in in-network utilization, timely intervention and outreach, real-time performance management (which has led to improved transfer rates), fewer avoidable utilization events, and improved readmission rates.
CarePort has led to improved communication and collaboration with PPCP’s partner providers, resulting in more meaningful conversations, streamlined efficiencies and workflows, and improved outcomes for the patients that PPCP serves – while also eliminating much of the administrative burden typically required to obtain this level of patient detail between disparate providers.