CarePort recently hosted a webinar featuring Constellation Health Services, a home health services provider in the Northeast that operates in Connecticut, Maine, Massachusetts, New Hampshire, New York, and Pennsylvania. Constellation is a highly rated home health agency – it has always been a five-star home health agency in New York, for example. Varying by region, Constellation provides services that include home health care, palliative care, hospice, and personal care, as well as ABA, occupational, and physical therapies. Joining us from Constellation were Al Azzara, Regional Director, New York, and Judy Walsh, Regional Director, Population Health.
Constellation faced care coordination struggles caused by gaps in patient care. Leveraging CarePort, the home health agency now has better visibility into a patient’s care before, during, and following home health services. Below we share the pain points that Constellation faced prior to implementing CarePort, and how the CarePort platform has helped achieve improved care coordination and positive patient outcomes.
Limited clinical context regarding patient history
Typically, when Constellation receives a referral, it’s only a snapshot of the patient’s current status; they aren’t often provided clinical context regarding a patient’s history within a referral.
With CarePort, however, Constellation receives a broader view of the patient’s medical history – oftentimes years’ worth of hospitalizations, SNF stays, and diagnoses for which the patient has previously been institutionalized – before even receiving the referral. This clinical context and background regarding a patient’s history is incredibly helpful when caring for a patient and developing his or her care plan.
Minimal real-time visibility into patient status
Prior to using CarePort, Constellation had difficulty tracking patients after they were discharged from Constellation’s care and intervening in real-time to collaborate on a patient’s care plan. For example, a universal pain point for home health providers is lacking real-time visibility into a patient’s emergency department (ED) admission, and instead learning of the admission days after the fact – when it’s too late to intervene and redirect the patient to home health care.
Leveraging CarePort, whenever a patient presents at the ED, is admitted to a hospital, or enters into a SNF, Constellation receive a real-time alert. This provides Constellation with the opportunity to contact the facility and speak with the case management department regarding the patient’s care. For example, if a patient presents at the ED, Constellation will contact the ED and inform them of their relationship with the patient to determine whether the patient can be managed safely at home. Without being made aware that Constellation was working with the patient – and the patient may not know or think to mention it – the ED may not understand Constellation’s capabilities, and that the patient could safely recover at home instead.
Ultimately, these real-time alerts regarding a patient’s care outside of Constellation increase communication and collaboration between providers and are effective in driving better patient outcomes. Patients often don’t remember which home care agency they used previously, especially when they’re hospitalized and in an acute situation. Not only can Constellation ensure care continuity by caring for a patient – often with the same clinical team – each time the patient requires home health services, but this also streamlines the discharge planning process for case managers as they don’t have to spend time searching for the appropriate home health services.
CarePort not only provides an alert if and when a patient is rehospitalized, but it also informs Constellation of the patient’s status, whether the patient is being observed, admitted, transferred to a SNF, or discharged to another home care agency – allowing Constellation to see where and how a patient is cared for at a given time.
Since working with CarePort, Constellation has achieved better connection to patients as they travel through the continuum, and have also strengthened relationships with acute partners. Better visibility into a patient’s care – whether through additional clinical context or via real-time alerts – has helped Constellation increase the number of patients repatriated back to their care.