CarePort recently hosted a thought leadership webinar with Preferred Primary Care Providers (PPCP), the largest independent primary care practice in Western Pennsylvania. Joining us for the discussion were Justin Dunn, Director of Operations and Planning; Vanessa Blaha, MSN, MBA, RN, Director of Care Management; and Stewart Gregerson, Operations Business Analyst all from Agilon Health, PPCP’s value-based care program partner for Medicare Advantage.
In this blog post, we’ll share how CarePort helps PPCP with active daily management. Stay tuned for our upcoming blog posts, which will detail how PPCP also leverages the CarePort platform for complex care management (CCM) and post-acute care workflows.
The need for an admission, discharge, and transfer (ADT) tool
As a physician group that manages global risk and looking to optimize patient care, PPCP needs to focus on foundational components that impact patient outcomes: knowing where patients are in the healthcare continuum, understanding patients’ utilization patterns, and having real-time visibility into where patients are seeking care.
Prior to implementing CarePort, PPCP struggled to obtain a complete picture of a patient’s current location, as well as his or her historical utilization. To gain this visibility, PPCP pieced together data from various sources – including ADT feeds, electronic medical records (EMRs), claims data, and patient lists – which was resource intensive, inefficient, delayed, and often resulted in incomplete information. PPCP sought a solution to understand emergency department (ED) visits, readmissions, and referral patterns from hospitals and post-acute providers – in real-time – rather than looking in the rear-view mirror using data that was three to six months old.
Real-time patient monitoring with CarePort
Implemented in January 2021, the PPCP team identified several use cases in which CarePort could help support the organization’s business model and help provide enhanced care and outcomes for their patient population. These use cases include:
- Active daily management
- Transition of care
- Complex care management (CCM)
- Post-acute care workflows
- Performance management
CarePort’s real-time data provides PPCP a more efficient means to intervene in a timely manner, enhance quality of care, and assess performance outcomes for patients they serve – as well as support the organization’s business model.
Use case: active daily management
As part of the active daily monitoring process, the PPCP team holds a quick morning huddle during which they log into the CarePort platform and complete critical tasks:
- Pull all data for patients currently utilizing services: Patients are segmented; for example, those who are good candidates for the CCM program are placed on a list that is sent to the case management team. This process is made easier by CarePort because of the platform’s ED high-utilizer flag.
- Examine all current patients in facilities: The PPCP team ensures each patient has an attending PPCP physician overseeing his or her care, and if not, their outreach team contacts the facilities to ensure doctors are properly being assigned patients.
- Monitor key trends: The PPCP team reviews critical stats including:
- The percentage of patients referred to preferred vs. non-preferred facilities
- Outcomes of previous day’s patient list to determine how many identified are good candidates for CCM program
- Trends outside of the norm or what are expected, and escalate these to the tier 2 huddle, where they will be discussed in more detail
Since implementing CarePort, PPCP has achieved efficiencies within workflows, better coordinated care internally and externally, and reacted in real-time to patient interventions. PPCP continues to uncover opportunities to leverage the information received in CarePort to enhance patient operations, quality of care, patient experience, and provider partnerships.