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Scripps Health: discharge planning, patient choice, and post-discharge monitoring

At ACMA National 2021, Scripps Health shared how the health system leverages the CarePort platform – a solution that is complementary to their EHR functionality – to streamline discharge planning, automate patient choice, and gain enhanced visibility into a patient’s care and utilization post-discharge. The session was led by Jay Larrosa, MSN, RN-BC, ACM-RN, PHN, FACDONA, project manager, system care management at Scripps Health.

Prior to implementing an electronic discharge planning solution, Scripps Health maintained patient choice lists for SNFs, home health, and hospice in multiple Word documents – which posed several challenges. These paper lists were difficult to maintain and ensure accuracy, and not easily shared with families or caregivers when they were not present. When looking to improve and streamline the discharge planning process, Scripps Health sought a technology that would align with their EHR. Scripps Health selected CarePort Care Management, as well as CarePort Guide – which can be integrated within Care Management – and CarePort Connect.

Streamlined Discharge Planning

CarePort Care Management is an EHR-agnostic solution that enables two-way communication with post-acute providers, allowing for closed-loop handoffs by providing all necessary information to post-acute providers and ensuring timely communication. Care Management also provides robust discharge planning analytics that enables hospitals to better monitor metrics around care transitions, post-acute provider performance, and patient outcomes.

In partnership with Epic and CarePort, Scripps Health developed a first-of-its-kind single sign-on (SSO) feature to reduce time spent logging into multiple applications. Leveraging the SSO jump feature, Scripps Health users experienced the following benefits:

  • Enhanced clinician satisfaction with fewer clicks required to access patient charts and only one confirmation of the patient’s identity at the beginning of the discharge process.
  • Increased productivity and efficiency by avoiding the login screen and patient search pages, and the ability navigate directly to an Epic JumpPoint-supported page for the same patient.
  • Improved patient safety and reduced potential PHI errors or HIPAA violations by direct access to a patient’s record when electronically sending documents to complete the discharge or referral placement.
  • Increased security by validating users’ access through active directory.
  • Improved documentation timeliness by providing direct access from the Epic EHR to Care Management to complete the discharge referral placement electronically.
  • Reduced cognitive load for case managers, discharge planners, physicians, and other staff by minimizing login requirements, eliminating the need for login credential memorization, and allowing for clinical expertise to remain the priority.

Automated Patient Choice

To offer patient choice based on quality, document choice to comply with discharge planning regulatory requirements and increase accuracy of patient choice lists, Scripps Health leveraged CarePort Guide. Integrated with Care Management, Guide offers a maintained national database of every Medicare-certified SNF and home health agency in the country. Accessed within CarePort Guide as an interactive tool or printed as a list, this information is intended to empower patients and their families to make informed decisions about post-acute care selection based on provider quality. As a health system that sends, on average, 26,000 referrals per month to 3,550 distinct post-acute providers in 29 U.S. states, utilization – and enhanced insight into that utilization – is a critical component of Scripps Health’s workflows.

As highlighted by Jay Larrosa during ACMA, also particularly beneficial to Scripps Health during the COVID-19 pandemic were the COVID-19-specific product enhancements implemented within Guide. These updated product features allowed Scripps Health the ability to view and sort SNFs based on availability and willingness to accept COVID-19 patients – as well as their isolation bed availability – not only helping to streamline the hospital discharge process and eliminate bottlenecks but also to improve SNF acceptance rates.

Enhanced Post-Discharge Monitoring

After patients discharge from a Scripps Health facility, transitional care managers receive real-time alerts regarding post-acute admissions, discharges, or emergency department presentations through CarePort Connect. Using real-time data and alerts via text or email, Connect helps manage patients across care settings – and allows hospital providers to monitor or redirect patients to the appropriate level of care to prevent unnecessary readmissions. Connect not only drives navigator workflows by generating alerts from specific facilities, but also provides increased visibility into previous utilization history to better inform care decisions or uncover potential social determinants of health.

To learn more about CarePort’s partnership with Scripps Health, refer to this case study.

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