Care Management Testimonials

We are excited to share testimonials of how RIQI’s Care Management services are helping organizations learn when their patients/clients go to the hospital and to skilled nursing facilities, so they can help coordinate and improve their care. We thank them for taking the time to share their incredible stories with you!

CODAC Behavioral Healthcare

Community Care Alliance

Rhode Island Primary Care Physicians Corporation (RIPCPC)

Addiction Recovery Institute (ARI)

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Hannah Hanson Health Home Team Coordinator, Addiction Recovery Institute (ARI)

How did things take place before Care Management Services?

Prior to having access to the Care Management Dashboard, we were unaware when a lot of our patients would go into the hospital. Sometimes, we get a dose confirmation call from a hospital, but often the staff at the facilities will not provide the admitting diagnosis or any other clinical information for us. Also, if it is a short hospital stay, we frequently do not receive any outreach, at all. Often, the only way we would find out this information is if the patient told us they had been to a facility. Given that self-reporting of these events can be unreliable, the information we had was very inconsistent. In particular, when they did not receive a dose of methadone while they were there, sometimes patients wouldn’t think to tell us if they were in the hospital if they did not stay for more than a few hours.

Also, in general, patients do not necessarily realize that we need to know this information. In many cases, our patients see the care they receive from us as being ‘different’ from the care they receive from other providers. They don’t understand the importance of our knowing what is going on so we are able to coordinate care with all of the providers they see. For example, when one of our patients goes to the hospital, we need to know what their discharge plan is. Sometimes patients would lose their discharge paperwork and they would not know if they have appointments scheduled. As part of the care we provide at Addiction Recovery Institute (ARI), we help coordinate their appointments, medications, and keep track of what doctors they are seeing so we can facilitate the best care possible from all entities. It was difficult to provide this level of support for patients when we were not getting this critical information.

How do things take place with Care management Tools?

Since having access to the Care Management Dashboard at ARI, we are now able to see, in near real time, when our patients are in an acute care hospital in Rhode Island. Sometimes, we don’t know why a patient hasn’t been to the clinic and we are unable to reach them through their contact information. Through accessing the Care Management Dashboard we can see if the reason they have not come in is due to a hospitalization. This is very helpful for us so we know where they are and we can be sure they are safe.

Additionally, when we see a patient is hospitalized, we are able to see the reason they are admitted and what facility they are in. In some cases, we are able to then send their case manager or nurse to visit them to see how they are doing. A room number is often available on the Dashboard, so this information helps for us to locate specifically where our patients are. In other cases, we may call and ask to speak to the patient via telephone. We have all of our patients sign a release so that they will know in advance that we can appropriately access this information.

Obviously, having information about patient Emergency Room visits and hospitalizations is extremely important for our follow-up and overall care coordination. When I see on the Care Management Dashboard that one of our patients is in the hospital, I put a flag in our record to let the Health Home nurse know. Through having this information, we are then able to prepare and have better coordination with all ARI staff members so they will be ready to see the patient when they arrive back from their hospitalization. Records can be requested proactively from the hospital before the patients are given their next dose of methadone. We are also better able to provide targeted support and counseling for patients. For example, we had an instance where someone who was high risk went to two different hospitals in one day. When he returned, he denied it. Knowing that he had been there opened a dialogue and allowed us to “have another leg to stand on” in the conversation. People in this situation may not be in the best place or mindset to talk about what has been going on in their lives. Having data helps us to provide improved engagement and support in this way.

How does that impact your life/work?

By having access to the Care Management Dashboard at ARI, we are able to make sure our patients are receiving the best possible care we can provide. This tool has reliable information that is beneficial to us. It allows us to support our patients, provide appropriate referrals and coordinate care as needed. Being able to access data about our patients’ hospitalizations, we are better able to coordinate proper care for them and assist in preventing future hospitalizations.
Through sharing information from the Care Management Dashboard with our staff, it gives them a point of reference and allows them to know where to reach out if they need background or more information. We don’t have to waste time calling around to different hospitals because we are informed about where our patients are going. Since we provide our patients with methadone, it is important for us to be able to see what is going on in regards to any of their other health issues. The Dashboard helps us to be informed in a timely manner so we can get the information we need.

We had an example of a patient who went to the hospital due to an overdose on a day that he would not have come to our clinic. With data from the Care Management Dashboard, we are able to have a different conversation with this individual than we would have been able to have in the past. We only see our patients for a short window: once they leave our clinic, we don’t always know what is going on with them. So having information that lets us better treat our patients in this way is really helpful.

CareLink

elissa Miranda, MBA, Director of Care Management Services; Helena Zaharakos, NCM; Bryan Los, Data Management and Reporting Specialist; Dan Faley, Community Health Worker; Kevin Johnston, Community Health Worker; Jennifer Wagner, NCM; Stephen Risi, Social Worker; William Walmsley Jr., MS, QMHP, Clinical Manager of Care Management Services.
Name: Melissa Miranda, MBA (Director of Care Management Services) Helena Zaharakos (NCM), Bryan Los (Data Management and Reporting Specialist), Dan Faley (Community Health Worker), Kevin Johnston (Community Health Worker), Jennifer Wagner (NCM), Stephen Risi (Social Worker); William Walmsley Jr., MS QMHP (Clinical Manager of Care Management Services)

How did things take place before you had the Care Management Dashboards?
Before we had the Care Management Dashboards at CareLink, we had no way of knowing if our members were in the hospital or not. Sometimes, outside agencies would call and inform us or we would get information about a hospitalization directly from a member. We had a lot of internal work to do in order to get the information we needed; and, our team would spend a lot of time communicating with external contacts.

Moreover, sometimes the demographic information we received for our members was not accurate. For example, we had many incorrect or invalid phone numbers for members, so it was difficult to provide outreach simply due to a lack of accurate contact information.

How do things take place with the Care Management Dashboards?
Using the Care Management Dashboards through the Rhode Island Quality Institute, we have experienced significant, positive results. The Care Management Dashboards has really changed the way we connect with our members and how we are able to introduce the Community Health Team-RI’s services. Having access to information about our members’ hospital admissions provides opportunities for us to go into the hospital and let them know we are available to help and their health insurance will cover the cost.

Since we started receiving information from the Care Management Dashboards, we have been more successful in connecting with members who were previously difficult to reach, in part, due to incorrect contact information.

“Using the Care Management Dashboards through the Rhode Island Quality Institute, we have experienced significant, positive results.”

Also, having information from the Care Management Dashboards, such as knowing a member was in the ED or hospitalized, lends us credibility when we call or visit them. We are more able to develop a rapport because we legitimately know what is going on and we can better tailor our conversations to meet their needs. This is also true for when we need to connect with staff at the hospital. Having information, such as a member’s room number, reason for visit and treating physician, helps establish credibility and move forward with coordinating care for a member.

Once our members are discharged, data from the Care Management Dashboards, such as the discharge disposition, is extremely valuable- particularly when we learn certain pieces of critical information, such as when a patient is deceased. Additionally, it is really helpful when we learn that a member is discharged from a Skilled Nursing Facility; so, we can be sure to provide the follow-up they may need.

With the Care Management Dashboards, we have a better understanding of which members should be designated as high risk and need our help. We can add to information provided by patients with specific, accurate data to inform our services. Using this information, we are better able to prioritize our efforts and evaluate who needs immediate outreach given a diagnosis and the number of ED visits they have had in the last six months. If we have not been able to connect with a member previously, and we see they are currently in the hospital, it gives us the opportunity to meet them in person and let them know we are here for them.

We have a number of specific examples of how the Care Management Dashboards has really made a difference in outcomes for our members:

  • In one instance, we identified a member who had 2 Emergency Room visits and 11 hospitalizations in the last 6 months. We had not been able to reach him previously because his phone number was disconnected. When we learned of his admission through the Dashboards, our staff went to the hospital and provided an introduction to the patient and his wife. The member called us right when he got out of the hospital. Now, he is receptive to receiving our services and support for a long list of needs, and we can help.
  • One member thought it was easier to go to the Emergency Room for every little thing. With information from the Dashboards we could see when he went to the hospital; and we reached out to him each time. Now, he prefers to reach out to us instead. When he changed his cell phone number recently, he let us know. Since he engages with our services, he is going to his PCP regularly and is more compliant regarding his health.
  • In another case, we have a member that is generally hard to get on board with treatment. Knowing that, when he would go to the hospital, we could reach out to the case managers and social workers in order to better coordinate care. They are really appreciative that we can collaborate to provide care to this member!
  • We were unable to reach a member who then appeared in an Emergency Room. She had a number of issues. She needed support to get food stamps and to find a PCP. We were able to meet with her and help her get these services. Now she is calling us and providing updates on her status. She is on board with our program now; and, we know we are making a difference in her life.
  • Even with a member that passed, we still can report a success story because we were able to reach out to her and support her right to the end. Everyone needs support from someone in these situations! The day she passed, we saw she was in the hospital first thing in the morning. We were able to make arrangements right away to be there for her. It’s a beautiful feeling when we are able to help someone in need in this way. If we didn’t have the Dashboards, we wouldn’t have known until it was too late.

How does that impact your life/work?
The Care Management Dashboards creates a “just in time” opportunity for us. By having information about our members’ admissions and discharges, we can connect with them when they need us the most. With the information we have from the Dashboards, we build trust and engagement. We can give our members attention and help for whatever the task may be- even for simple things, like helping them fill out a form. Case Managers in the Emergency Departments are often overwhelmed because they have so many activities they need to set-up for patients. It makes it easier for them when we are able to coordinate care and they know they can rely on us to get the services a patient needs beyond the hospital setting. The member may require treatment for back pain, but through services provided by our Community Heath Team- RI, they may also benefit from SNAP, social services, housing or another type of support once they are discharged. We can make referrals to other agencies that can get involved and help ensure follow-up is complete. Additionally, we find that, once we establish a rapport, members actually prefer to talk to us rather than go to the ED. So this opportunity for engagement can help decrease unnecessary ED use which is more cost effective for everyone.

"With the information we have from the Dashboards, we build trust and engagement."

With the data we can get from the Care Management Dashboards, we can track more successes in our future and develop reports to analyze how we may improve. We will be more able to assess trends in our population and more effectively develop interventions. If we find that homelessness or drug and alcohol abuse are significantly correlated with our members, who are utilizing hospital facilities, then we can target these issues more specifically.

We feel good about the improvements we have had so far with the Care Management Dashboards. Most importantly, when we are better able to connect with members, it lets them know they have the CareLink Community Health Team- Rhode Island as a part of their Care Team. They can utilize our support and services and move towards better health.

Center for Treatment and Recovery (CTR)

Brittany Fiola, Medical Assistant, Melissa Souza, RN, Director or Nursing and Vance Velletri, LPN, Dosing Nurse
Brittany Fiola, Medical Assistant, Melissa Souza, RN, Director or Nursing and Vance Velletri, LPN, Dosing Nurse

How did things take place before Care Management Services?
Before we had Care Management Services at the Center for Treatment and Recovery (CTR), we depended on the hospitals to communicate to us and send us discharge information for our patients. Typically, upon admission of one of our patients, hospital staff will call CTR to confirm dosing information with our nurses. But, when staff from the hospitals didn’t call to confirm dosing, we would have to rely on patients’ self-reporting to us that they had been to a facility. If the patient didn’t inform us, sometimes we would never know that they had gone to a hospital. In some cases, if a patient hadn’t been in to our clinic for two to three days, we would call their emergency contact and learn that our patient was hospitalized. Additionally, there would be times when we wouldn’t know about a hospitalization until we were informed much later from their insurance company.

“We discuss information from our Care Management tools in our staff meetings on a regular basis to determine appropriate treatment, including interventions by our counselors and to decide if a patient should have more intensive follow-up with the provider.”

Along with issues around being reliably informed about hospitalizations, there were a number of other significant challenges that we were experiencing. For example, planning for our patients’ discharges was difficult because we were not typically informed when this was happening. Once we did learn of a discharge, we would call the hospital to get a record of our patient’s last dose, but hospital staff often wouldn’t provide any further information about the hospitalization or the reason for the admission. We would then either need to call or fax a release to the hospital in order to get the needed discharge summary. When we did this we would not always hear back from the hospitals right away after faxing the release, so we would have to wait until we received this data. Once we receive the paperwork, it would sometimes have a minimal amount of information, such as bloodwork and a current medication list. In some cases, even their record of the patient’s last dose was missing. We spent a lot of time submitting releases in order to get needed discharge paperwork and tying together the information we required.

There were a number of risks involved when hospitals did not communicate with us: In some situations, hospitalized patients were at risk of not getting correctly dosed if the most recent dosing information was not obtained from us. Also, when we were not informed about a hospitalization, we could be unaware of a new diagnosis and or newly prescribed medications that might possibly interact with their Methadone treatment. Given these factors, we spent a great deal of time working to get the critical information we need.

How do things take place with Care Management tools?
Now that we have our Care Management Alerts and Dashboards, we receive an Alert as soon as our patient has been admitted to an acute care hospital or Emergency Room in Rhode Island. We are also informed when they are discharged. We are not ‘out of the loop’ like we had been previously: we don’t have to rely on the hospitals calling us or the patients self-reporting when they have an admission. This makes it much easier for CTR to coordinate care with the hospitals and our patients. Our whole process is more organized and it doesn’t take as much time because everything is all right there. We do not have to go back and forth requesting information from the hospitals, like we used to.

“[With Care Management tools], we are not ‘out of the loop’ like we had been previously: we don’t have to rely on the hospitals calling us or the patients self-reporting when they have an admission. This makes it much easier for CTR to coordinate care with the hospitals and our patients.”

With our current process, when we receive an Alert, the nurse is notified of the event. They can check our records to see if the hospital has already called for dosing information. Then, we can monitor the Care Management Dashboards for the discharge and be prepared for the patient to return to our care. We are able to use the discharge disposition codes included in the Dashboards to help us know where our patients are and what follow-up is needed. Also, we discuss information from our Care Management tools in our staff meetings on a regular basis to determine appropriate treatment, including interventions by our counselors and to decide if a patient should have more intensive follow-up with the provider.

There have been many instances when Care Management tools have been uniquely helpful. For example, when hospitals don’t call and confirm dosing, we can be prepared for when the patient is discharged and will return to our care. Sometimes, after a hospitalization, a patient may not be on Methadone anymore. In one situation, we had a patient who was discharged but did not return to our care. We were able to reach out to confirm the person’s status and make sure they were all right. For patients who frequently go in and out of the hospital, we have observed that staff at the hospitals sometimes use dosage information on file from the previous hospitalization. As dosing can change with some regularity, it is really important for them to communicate with us each time the patient is newly admitted to their facility. There is definitely space for improvement for communication with hospitals, and Care Management tools are helping with this.

Along with the reliability and timeliness of Care Management data, we also get more complete information. We are no longer limited by our patients’ self-report or the minimal information we used to receive from the discharge paperwork we receive from the hospitals. With Care Management Alerts, we receive a copy of the Lifespan Discharge Continuity of Care (CoC) document (when a patient goes to a Lifespan facility). This CoC document is more detailed and helpful than the paperwork we would otherwise receive from patients when they remembered to bring us this information. Particularly when the patient is not enrolled in CurrentCare, this document can be key to getting the information we need.

Having the Care Management Dashboards helps us in other ways. For example, we are now better able to track the number of Emergency Room visits and admissions our patients have. We need this data for our Health Home reports. Additionally, sometimes we are able to get updated and correct demographic information, such as telephone numbers (which can change with some frequency) so we are able to contact our patients, when needed.

Since we started using the Care Management Dashboards, we have also benefitted from knowing when our patient is enrolled in CurrentCare. With CurrentCare we can get additional information that helps support the care we provide. For example, in CurrentCare, we can find lists of diagnoses and medications. When we have this data, it is easier for us to determine if there is a health concern that takes priority and needs to be worked on more than other issues. For example, one of our patients had an issue with alcohol but we had not previously been informed about this piece of this individual’s history. Through knowing this, we are better able provide care that is safe and best meets the unique needs of our patients.

How does that impact your life/work?

“The impact of having Care Management Alerts and Dashboards is that we now have better knowledge about the all-around care of our patients. This data helps us be aware of issues that could impact a patient’s treatment episode negatively here at the clinic.”

The impact of having Care Management Alerts and Dashboards is that we now have better knowledge about the all-around care of our patients. This data helps us be aware of issues that could impact a patient’s treatment episode negatively here at the clinic. It’s a very helpful tool for coordinating care and facilitates us to be organized and provide the best care for our patients. This obviously affects patients in a positive way.

We have a small group of staff here at CTR and we work together closely. Many of our patients are good at calling and we develop relationships with them. But, before we had our Care Management tools, we didn’t realize how many different hospitalizations we didn’t know about. If patients didn’t inform us and bring us their paper work, we simply didn’t know. Now we know every single time. A patient could have been in a hospital overnight and then come to us the next morning. Now we can always be sure to be aware when this happens so we can verify that the dosing is correct and safe. When our patients are in the hospital for a more extended time, nurses can monitor and keep track so we can be better prepared when they return. It’s helpful that our staff can be aware of a discharge so they can ask the patient how they made out at the hospital and support this communication.

When there is information that we can’t find in the Dashboards, we can often find what we need in the CurrentCare Viewer. Using CurrentCare makes it easier to find important information regarding bloodwork and medications. CurrentCare also helps improve data collection for state reports for our Health Home population. We need to complete a quarterly report in which we track blood pressure, BMI, glucose levels and admissions. These tools really help pulling this data together.

CODAC Behavioral Healthcare

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How did things take place before Care Management Services?
Before CODAC had Care Management tools, we would typically receive a telephone call from the hospital notifying us when one of our patients went to their facility. Our patients usually report they are receiving Medication-Assisted Treatment (MAT), so staff at hospitals in Rhode Island know to reach out to us. It is important that we communicate with the hospitals to confirm a patient’s last dose of medication that was administered. Approximately 9 out of 10 times we would hear from the hospital. But, some hospital encounters would fall through the cracks. In these situations, we often would have no idea why the patient went to the Emergency Room or if a hospital admission followed, and we frequently would not have any paperwork from the hospital visit. When we did receive information, it would be very sparse. We might receive only a medication list or other limited details written on paper discharge summaries. In order to get more information, we would have to fax a release to a facility. Then we would often end up waiting days or weeks before we would receive the information. It wasn’t unusual that we might make up to as many as 5 or 6 phone calls to a facility before we would finally receive discharge information.

Some of our patients do not require daily receipt of their dosing and have a ‘take home’ status. They are scheduled to pick up their medication every 6 or 13 days. In these cases, we often wouldn’t know if the patient had a hospital ED or inpatient visit during that time unless they happened to tell us. When this happens, the treatment provided at the hospital may impact the treatment we provide. For example, if a patient goes to the hospital due to an overdose of a substance, such as alcohol or a Benzodiazepine we need this information to assess the patient, address the incident and make clinical adjustments, as appropriate.

In addition, if we are not informed when a patient is suicidal, then it is obviously difficult to make needed changes to the care we provide. In order for us to provide the safest, best care, we need a reliable means to receive this critical information in a timely, efficient manner.

How do things take place with Care Management tools?
Care Management Alerts are now reviewed at each of our sites on a daily basis. Key information about our patients’ admissions and discharges is shared with staff and also entered into our Electronic Health Record (EHR). In our EHR, we are able to track how long patients are in the hospital and when they are discharged. Through this process, we are able to review particular cases and determine who needs intervention. Having the Reason for Visit for our patients’ Emergency Room or Inpatient admissions is extremely helpful for us in this process. Also, patients seldom “fall through the cracks” since we can now proactively contact the hospital to confirm dosing rather than having to wait for them to call us.

“For us, the use of Care Management tools is truly lifesaving. That is without question. If we understand that a patient overdosed at the hospital last night and was subsequently discharged, we can then change our treatment as needed, to keep this individual safe.”

Optimizing Patient Care with Care Management tools
Since we started monitoring patient Emergency Room and Inpatient encounters via our Care Management Alerts and Dashboards, we have had a number of occurrences in which a patient has gone to the hospital due to substance use. Now that we receive information through our Alerts, we can be more proactive in the care we provide for these individuals. In these situations, we are able to promptly change their dosing status and more closely monitor the person’s symptoms and care when they are discharged from the hospital back to us. Because we have Alerts, we are also able to better monitor our frequent high utilizers of hospital services. If we see that they are going to the ED often, they may need higher levels of intervention. Often our patients who have Severe and Persistent Mental Illness (SPMI) fall into this category. For these individuals we need to provide important outreach and monitoring if their condition worsens and they need to be hospitalized.

When someone is discharged from the hospital, for certain hospital systems we receive a Care Management Alert with the patient’s continuity of care summary attached. Once we have this information, we can start preparing for when the patient will return to the clinic for their next dose. We are able to take action faster and be ready with the data we need ahead of time so documentation and procedures for that patient can be completed before they arrive. This includes coordinating with the hospital to confirm dosing, which is needed before we can safely administer a patient’s medication. Receiving the Lifespan Continuity of Care (CoC) document with our Alerts is helpful in this process. It allows us to quickly find important information, such as the discharge diagnoses (when our patients go to Lifespan hospitals). As our documentation can take up to 2 hours to complete, being able to initiate this process in advance of a patient’s arrival is very beneficial for them. This way, patients do not have to wait at our facility and they can receive their medication right away. Also, knowing in advance that the patient has recently been discharged from a hospital, gives our staff the opportunity to touch base and check in with the patient about how they are feeling.

With Care Management tools, one of the things that we are alerted to is the seriousness of certain medical conditions that may jeopardize their health. In many cases, we would not have known about some of the medical reasons our patients are hospitalized. For example, when a patient is having issues with breathing and episodes of Chronic Obstructive Pulmonary Disease (COPD) that lead to hospital admissions, we can provide additional, targeted interventions when they are discharged. In such cases, we may be able to help the patient by providing more frequent appointments and education, as needed. We also have pregnant patients that need to be specially monitored and have unique needs. Stressors and trauma which may occur when an individual is in an accident can really impact their lives and their status with us. Now that we are alerted when a patient goes to the hospital, we are better able to provide optimal support for their overall health when they return to CODAC.

Along with helping us to be more aware of medical conditions, Care Management data has also emerged as being extremely useful in letting us know when patients who are on take home status have a scheduled surgery in between receiving their doses. Prior to having Care Management tools, we would not necessarily be aware when this was happening. Knowing that a patient is having surgery significantly impacts our treatment and follow-up for our patients.

Improving Care Coordination with Care Management tools
Having data from Care Management tools also helps to develop rapport with staff in the Emergency Rooms and hospital units. When we know our patients are at their facility, we can outreach directly to them to coordinate care. We have been working with discharge planners and staff at the hospital to have better processes that can lead to improved outcomes for our patients. It is a great example of the medical community providers working together to support seamless interventions that are in the patient’s best interest.

We also are more effectively engaging in conversations with the managed care providers that work with our patients. Having this communication aids continuity of care in situations when our patients have frequent hospital admissions, particularly when they are diagnosed with co-occurring disorders. When we receive a Care Management Alert about an admission, we can reach out to managed care providers while the patient is still in the hospital. This can be very beneficial, as there are things that hospital social services can do to more effectively help a patient with certain situations, such as a need for housing or a need for transition to a higher level of care (such as a residential placement). Rather than let them out on the street from the hospital, we can coordinate care to get them directly into the most beneficial environment that is appropriate to the level of care they need.

”Our Heath Home nurses really love Care Management tools. They took to using Alerts and the Dashboards very quickly. It’s made them so much more effective in their jobs because these tools really make their jobs a lot easier.”

Using Care Management Data for Planning Improvements in Care
In our Care Management Dashboards, we have started to assess the trending data that is available from the last year. Through an evaluation of this information, we identified 43 patients who have had 10 or more admissions in the last year. We were also able to ascertain that, 88 percent of the time, our patients go to the Emergency Room due to medical issues they are experiencing. We had expected that there would be a greater frequency of ED visits due to substance use or an exacerbation of anxiety (or other psychiatric issues), so it was very helpful to learn that this is not necessarily the case. In the future, knowing this information will allow us to segment the medical conditions that are most commonly presenting so we can develop specific wellness programs around those admissions.

Community Awareness
With information from the Care Management Dashboards, we are also better able to have a broader sense of when issues are impacting our patient community. For example, when we learn immediately that one of our patients has passed away in the Emergency Room or during a hospital admission, it is very helpful for us to receive this information. Often other individuals we treat may know them, too. The loss can have a significant impact to our patient community as well as our clinicians and staff who are providing care. When we are aware of a patient passing, we can then be ready to provide support for those affected who may be grieving the loss.

“Using Care Management tools has also helped us to focus on our philosophy of integrated care.”

How does that impact your life/work?
For us, the use of Care Management tools is truly lifesaving. That is without question. If we understand that a patient overdosed at the hospital last night and was subsequently discharged, we can then change our treatment as needed, to keep this individual safe. When we know our patients are having issues, we can provide targeted interventions that are timely and beneficial.

Our Heath Home nurses really love Care Management tools. They took to using Alerts and the Dashboards very quickly. It’s made them so much more effective in their jobs because these tools really make their jobs a lot easier. It is a great time saver in the work we do! We used to have to wait days before we would receive critical information. Now, with Care Management tools, we have the information right away. Because of this, we are spending more time with our patients, not tracking data. It has improved our quality of care because we are more clinically informed.

“[Care Management tools have] improved our quality of care because we are more clinically informed.”

Using Care Management tools has also helped us to focus on our philosophy of integrated care. When we started receiving Care Management data, we found that not all patients were happy that we had this information. It was important that we communicate with them about the importance of our being informed about their hospitalizations as part of the full scope of treatment we provide. To provide care that focuses on a holistic approach and one that also addresses the needs of a community, it is important for us to understand all elements of our patients’ health. As we develop wellness program based on our analysis of data in our Dashboards, we are better equipped to identify and address the variety of health issues prevalent in our population. We will then be able to assess our success by monitoring data trends to see if admissions decrease given the treatment that we provide.

Finally, it has been valuable to learn that approximately 80-90 percent of our patients are already enrolled in CurrentCare. In the future, being able to get CurrentCare data can potentially be a cost saver as we can prevent having duplicate laboratory tests ordered. This is particularly helpful for our Providence Office, where we house some programs to treat infectious diseases. When we learn that a patient has gone to the hospital, we can check in CurrentCare to see what labs were done at the hospital so we can have the information we need.

Community Care Alliance

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Co-Director of the Community Support Program: Kelly Kobani, Co-Director of the Community Support Program: Randi Case, Director of Nursing: Susan Corkran

How did things take place before Care Management Services?
It is very important to us that we are informed when our clients are in the hospital, as it is during these times when they might particularly need more support and coordination around treatment issues. Before we had the Care Management Alerts and Dashboards at Community Care Alliance (CCA), we often didn’t know when they were in the ED or Hospital setting. We would always find out after the fact. Sometimes, we would find out weeks later when they would tell us, “I was there 3 weeks ago because X happened.”

When they did tell us they had been hospitalized, we would then have to do research as to why they were there so we could know important details about what really happened. We would need to ask the client to sign a release so we would be able to get the records we needed. In many cases, weeks would go by before we would receive the documents. Sometimes, we might have gotten a call from the Primary Care Provider and we could coordinate a bit, but this didn’t happen very often. It depended on the client and the particular treatment issues at the time.

In addition, prior to having the Care Management Dashboards, we had a hard time keeping track of how frequently people were going to the hospital. Knowing if they were a high utilizer of EDs and/or Inpatient services informs our care and helps us address our clients’ treatment needs.

How do things take place with Care Management tools?
Now, our Hospital Liaisons and Medical Assistants are regularly using the Care Management Dashboards to see when their clients are in the hospital. They send the information from the Dashboards to the appropriate team members who are then able to provide follow-up. With Care Management data, we are able to provide better follow-up and we do not have to rely on our clients reporting this information to us. Because we are informed, we can initiate to make sure the care coordination happens. Often, when we receive this information, the clients are still at the hospital, so we can coordinate directly with the staff at that facility. We can let them know our thoughts on what the individual patient’s needs may be. Because we have a specific workflow in place, we know that we have staff assigned to do the follow-up that is needed and we are better able to connect with the client after discharge.

“Clients have let us know that it feels good that someone is paying attention and providing this outreach.”

In the beginning, when we first started using the Dashboards, some clients were surprised that we knew they had been to the hospital. Now, they are used to it. They don’t know how we get the Alert, but it is something that they realize is normal because part of our role is to help coordinate their care. Clients have let us know that it feels good that someone is paying attention and providing this outreach.

Care Management tools have also helped with putting together certain ‘puzzle pieces.’ For example, clients with substance use issues would sometimes go missing. Now that we are using the Dashboards, all of sudden one of these clients would surface and we could then coordinate and make a plan and bring that individual back into the loop. Sometimes we learn that they have ended up in a different community, such as Newport, so we know that they relocated.

“Now, with the Care Management Alerts and Dashboards, we can all be on the same page. These tools allows us a chance to have better coordination and collaboration in care with both the client and their providers.”

We had one recent situation in which there was a person who we couldn’t find. We had exhausted outreach efforts. Then we found the patient was medically admitted into an inpatient setting. The CCA Case Worker made a plan to meet with the person to find out what had been going on. When the Case Worker went to the hospital, the client was very appreciative. No one else had visited this individual while they were in the hospital. This interaction really motivated the client to reengage in treatment.

How does that impact your life/work?
Now, with the Care Management Alerts and Dashboards, we can all be on the same page. These tools allows us a chance to have better coordination and collaboration in care with both the client and their providers. We can have the conversation with the client that, “this is not just about your mental health: it’s about your whole being. We care about you in your entirety.” Because we are informed, we can reach out to primary care (or vice versa) and communicate that both parties are receiving Alerts for a particular client.

There are a number of other ways the Care Management Dashboards is helpful for our organization. For example, the fact that you can go back in time to see previous encounter information, such as where a client was two months ago, or any time in their past Care Management record, is very useful. Being able to see the Reason for Visits for the previous encounters can really help understand a patient’s history. Also, all of the demographic information available can be helpful. Sometimes, finding an updated address and phone number in the Dashboards can help us to get in touch with a client whose contact information may have changed.

“Using Care Management tools, we have implemented workflow around our risk management for clients who have been identified as high utilizers of hospital services.”

Using Care Management tools, we have implemented workflow around our risk management for clients who have been identified as high utilizers of hospital services. We are able to target this population for outreach when we have care coordination meetings with our team. The Care Management Dashboards helps us to identify who is frequenting hospitals so we can then determine what interventions are needed to help decrease unnecessary usage. The new risk scores that are available are useful in this task.

Finally, it’s helpful for being aware when patients are enrolled in CurrentCare so we can then access more clinical information in the Viewer. When we know clients are not enrolled, offer them the opportunity to sign-up.

Comprehensive Community Action Program (CCAP)

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Names: Monica Martin, Team Nurse; Sandra Cameron, Triage Nurse; Gina Eubank, Director of Operations; Julie Lemaire, Nurse Care Manager Supervisor; Diane Grace, Nurse Care Manager; Evelyn Sanchez, Nurse Care Manager; Corrine Robinson, HIT Administrator; Amber Johnson, Quality Assistant; Cesar Ramirez, Medical Records Coordinator; Arthur Taylor, Director of Nursing; Anjelica Mercadante, Nurse Care Manager

How did things take place before Care Management Services?
Prior to having the RIQI Care Management Alerts and Dashboard at Comprehensive Community Action Program (CCAP), we relied solely on CurrentCare Alerts and the information that we would receive from the facilities that were seeing our patients. While CurrentCare Alerts were helpful, we would only receive those Alerts for patients enrolled in CurrentCare who identified one of our providers as their PCP. Approximately 50% of our patients are enrolled in CurrentCare, so this did not cover a large number of patients we treat. Also, we usually get notifications via fax from the hospitals when our patients are discharged. If the patient couldn’t remember his PCP name when they were asked at the hospital, the record would be ‘lost’ from us until we requested it. We would hope and pray that the patients remembered the name of their PCP when they went to the hospital so we would get records and be contacted.

Given these limitations, our efforts to follow-up after a patient was discharged from a hospital were all reactive and not proactive. We had to rely on our patients knowing to identify their CCAP provider to the hospitals, so we had no way of consistently knowing, all the time, when our patients were using emergency department facilities or being admitted to the hospital. We also had to do a lot of work trying to get data from the hospitals and sorting duplicate notifications, as we would receive both fax notifications as well as CurrentCare Alerts for many patients.

Of course, when we did get a notification, we would outreach to the patient and schedule a follow-up appointment. But, when we were not alerted, we would often have to scramble to get records when a patient would come in for an appointment at a later time and let us know they had been to an emergency room. We would be searching for stuff and our timing would sometimes be off. For example, sometimes, in the past, we would get a notification that the patient had an inpatient stay, but they were actually still in the hospital. We would outreach and someone at their home would answer and let us know that our patient hadn’t been discharged yet. Given the gaps in the data we were receiving, it was very difficult to implement a reliable workflow around providing consistent follow-up care for our patients.

How do things take place with Care Management Tools?
In June of 2018, CCAP had the opportunity (through TCPI grant funding) to receive RIQI Care Management Alerts and Dashboard information for our full panel of patients. We included all of our patients who had been seen in one of our facilities within last 18 months. Prior to having this data, we thought we were doing well in identifying our patients who were going to the emergency room. We believed we had a small group of approximately 30 patients per month who were over utilizing the emergency services in the state. It was very eye opening to discover how few hospital notices we were actually receiving. Once we started reviewing our full panel data in our Care Management Dashboard, we learned that the number of patients going to the Emergency Room each month was close to 550 patients! We were truly surprised to learn that we were getting maybe 30% of notifications from hospitals prior to implementing our full panel in the Dashboard.

As previously mentioned, one of the biggest challenges in the past is we would get reports through the fax and it was not clear if the patient had been discharged or was still admitted. Now, with Care Management Tools, we get near real time data. We can see where they are and we are informed by the discharge disposition codes that are included. Sometimes, through the disposition code, we will know specifically that they are going to a skilled nursing facility. It is also very helpful and interesting to see why (the reason for visit) our patients are going to the Emergency Room, and having the updated demographics that are included is very valuable. Our records sometimes need to be updated and we can get this information from the Dashboard. If they have gone to the hospital, we can go into the Dashboard and see the phone number they provided three days ago. As we are always needing to be ‘detectives,’ having this kind of information about what is going on with the patient is extremely valuable to help triage what follow-up will be more beneficial and then be able to successfully contact the patient.

Now that we have our full panel of data, a challenge we face is making sure that we are able to manage the volume of patients that we are identifying as needing interventions and follow-up. Once we started to have an understanding of the scope of information that is now available, we put together a workgroup to determine the best workflow for us to follow. Previously, our Nurse Care Managers would get information for every patient that went to the Emergency Room (when we received a notification). They were getting information for everybody and then they had to do clerical work, update charts and decide if they should take a patient as part of their high risk caseload or assign them to the staff nurse on the team. Now, with the new process that was developed, that clerical work is being done by other staff who can handle the associated reporting. When we get Care Management Alerts, our Referral Team initially receives the information. They pull the patient’s record together and give it to the nursing team who updates the chart and provides outreach, as needed. We are working to act on the data and provide outreach within no more than two days from the time we learn about their encounter. Also, with Care Management Tools, we can track how many times patients go to the Emergency Room in the last six months. If they have gone three or more times, the Nurse Care Managers automatically take them into their caseload and provide targeted follow-up and education.

Overall, with this new process, the Nurse Care Managers can put more focus on actual patient care instead of administrative duties. This redesigned workflow allows for more face to face contact and outreach. Importantly, with this process in place, we are able to give extra service to the patients that really need it. Hopefully, over time, these efforts will reduce the number of unnecessary Emergency visits by our patients.

How does that impact your life/work?
Having Care Management Alerts and Dashboards has had a huge impact on the effectiveness of our nursing staff at CCAP. For the Nurse Care Managers on the team, our efforts are really focused on calling and reaching out to patients when they are identified so we can help prevent them from being readmitted. Armed with the information we receive from Care Management Tools, we can better assist our patients in maintaining their health and managing their comorbidities. We have gotten feedback that patients are impressed that we knew they were in the hospital and by the speed that we can connect with them – and that feels good. Also, sometimes our nurses are happy that they made the call because many patients really appreciate the outreach and feel cared about.

Now that we are more reliably and efficiently receiving information about utilization of hospital services, significantly more Emergency Department follow-up appointments are being scheduled at CCAP. We are getting people in who need the support that our teams can provide. As a recent example, there was a patient who was seen by us last in 2017. Through our Care Management Tools, we got a hospital update and learned she had been assaulted. One of our nurses called the patient, and when she picked-up the phone, she was crying. Before getting off the phone, the patient was scheduled for an appointment to come-in. We can be sure to provide her with further support and assistance after she is discharged. While it is a lot of effort to provide this level of follow-up and support, through this level of care, we can further prevent patients unnecessarily going to the Emergency Room.

Of course, there are many issues that continue to need to be addressed. With our new workflow, there is another layer of work for our staff, as the volume of follow-up that we need to take care of is significant. Also, for the nurses who provide direct patient care, some days can be tough. Given the current Opioid Epidemic, we are needing to address more issues relating to overdoses. Some patients receive Narcan and emergency treatment and then they don’t realize how at risk they are. Also, it was eye opening to start receiving more information about how many patients are going to the ED due to alcohol and drug use, as well as other behavioral health issues. Particularly for staff who do this work every single day, providing support for patients can be emotionally challenging.

But, we have no question that the efforts we are putting into this new workflow and enhanced patient care is worth it and will have long-term positive impacts. In particular, we find that there is a direct correlation between the care we provide and the amount of utilization we see. In the past, access was a challenge at CCAP. When patients call and can’t get an appointment, they are more likely to go to the hospital. But, now we are aligned to help break this cycle, as we have more access than we have ever had. With having more providers on staff and increased access we can help prevent unnecessary utilization of hospital services. Already, in the short time we have had our full panel, we can identify a handful of patients who seems to have reduced the number of times they are going to the Emergency Department for care. For patients that have not recently engaged with staff at CCAP, when we receive information through Care Management Tools, we can call and touch base with these individuals. It’s a nice way to reengage and communicate. We try to remind patients that we have extended time evening appointments and weekends. Hopefully, the more we educate, they will learn to call us instead of going to ED when they need medical attention and support.

Discovery House Woonsocket

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Amy Lomastro, Nurse Supervisor and Health Home Team Coordinator

How did things take place before Care Management Services?
Before we had the Care Management Dashboards, there were a lot of times that we wouldn’t know our patients were in the hospital. We had to rely on our patients reporting this information to us. If they told us, we would then need to get a consent and fax over a request for their records from the hospital. Sometimes our patients wouldn’t think to report this information to us. So, in some cases we were never alerted about ED visits and hospitalizations.

How do things take place with Care management Tools?
Now that we have the Care Management Dashboards, we are able to see where our Health Home patients are when they go to the hospital. If the patient already has a release in place, we can simply call over to the hospital and make sure they have the correct dosing information for our patient. If a patient had been AWOL, we can find out if he or she has gone to the hospital, which is very helpful to confirm.

With the Care Management Dashboards, we can also be ready for when patients come back to our program once they are discharged from the hospital. When we get information about a hospitalization from the Dashboards, we put an alert in the patient’s record, so when they arrive, the medical, nursing and counseling can all be ready to follow-up. If we don’t already have a release in place, we can have a release form ready for them to sign so we can get the records that we need. Our nursing staff can confirm the patient’s last dose and each patient who has been hospitalized also sees the doctor and their counselor.

“Because we dispense Methadone, it is really critical for us to know about all the health issues our patients have so we can be sure the treatment we provide is safe. Having information from the Care Management Dashboards helps with this and supports the case management element of our Heath Homes.”

How does that impact your life/work?
Because we dispense Methadone, it is really critical for us to know about all the health issues our patients have so we can be sure the treatment we provide is safe. Having information from the Care Management Dashboards helps with this and supports the case management element of our Heath Homes. With the Dashboards, we are better able to know when our patients are having health issues and are not surprised to learn about a hospitalization after the fact. It’s really helpful that we can see the Reason for Visit so we can have an idea of what to expect when they come back, such as what education and referrals they may need. We can assist them to make sure they schedule appointments after discharge and assess if they need additional medical follow-up. It also helps with knowing when to communicate with the facilities during hospitalization so we can know when to be reaching out for records and coordinating care.

An example of a specific improvement we have been able to put in place with the help of data from the Dashboards is in relation to patient intoxication. We need to be careful about dosing patients when they may be using Alcohol, Benzodiazepines or other substances. With the Dashboards, we have been able to learn when patients have been to the hospital due to intoxication. Because of this, we were able to complete breathalyzer and urine testing protocol for these individuals so we can keep these patients safe.

Fellowship Heath Resources Rhode Island (FHR)

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Emily Roderick, Regional Administrative Coordinator at Fellowship Heath Resources Rhode Island

How did things take place before Care Management Services?
At Fellowship Health Resources, our primary function in the community is to coordinate care for our clients. There are numerous situations in which our clients sometimes need to go to the emergency room and be admitted to the hospital. For some, we may have tried everything we can to balance their medications in an outpatient setting, but they simply need more intensive help. For example, clients who are coming off or going on an injection need a higher level of supervision and therefore typically need to be inpatient for these adjustments. We also have clients who may have had an overdose. Life threatening circumstances that sometimes occur include clients drinking alcohol and using Klonopin. This may happen either on purpose or by accident. Additionally, if a client is acting out in the community, they may need to be evaluated by police in the community (clinical social workers) and need to go to the Emergency Room.

Having information about hospitalizations helps us to support a team approach when we can connect with medical professionals and make sure clients are receiving the care they need. Before we had Care Management tools, we really relied on hospitals to send discharge information to us, or we would have to ask clients to provide a release so we could get important information about their hospitalizations. Typically, hospitals would only call us when specific psychological issues were involved or for a patient that they already knew we were treating. When the hospitals didn’t inform us, sometimes we would never know that our client had been to their facility. This was challenging because it is critical for us to be aware of this information, even for medical reasons such as flu, so we can help make sure follow-up is provided.

Additionally, in the past, our processes to get hospital data were fairly manual. We would often have to call hospitals to request and fax releases. There would be times we would have to do additional follow-up because we wouldn’t get a response. Sometimes we would learn about a previous hospitalization through information provided by an insurance company. So there was a lot of time and work involved in trying to get the information we needed.

How do things take place with Care management Tools?
Now that we have Care Management tools for the clients we treat, we don’t have to rely on clients self-reporting their hospitalizations. Given this, we gain a broader understanding of our clients outside of our community. When we get information that is pertinent, such as learning a client has been in a car accident, knowing this information can support our clinical care and provide guidance for what interventions this individual will need. Since we receive Care Managements Alerts, I like that, for Lifespan Hospitals, we receive a Continuity of Care document as an attachment for all of our clients discharged from their facilities. In the past, we didn’t always receive this, as clients don’t always share with the staff at the hospitals that they are being treated by us, due to the stigma of behavioral health. Having this document helps us have a richer sense of what is going on so we are able to provide better care.

Earlier this year, before we had Care Management tools, the state provided us with a list of “high utilizer” clients who were frequently going to the hospital. We were really surprised by the list. In particular, about 15 clients were included that we had no idea of the degree they were being admitted. With Care Management tools, we can monitor and see the clients who are going in to the hospital regularly. We may have been checking in on them while they are in the community, but now we really know when they are having problems that we can help them with. It has been a very helpful indicator to help us know when greater intervention is required for these individuals. In most cases, they may have difficulties with behavioral and medication issues and we can help coordinate and provide support.

"With Care Management tools, we can monitor and see the clients who are going in to the hospital regularly."

I can also add that, as a Community Mental Health Organization, we are responsible for providing follow-up within 7 days of a hospitalization. In the past, we didn’t always know when these appointments needed to be scheduled. Now, with data from Care Management tools, we can always be sure to provide this care that is expected of us.

How does that impact your life/work?
In my role, I do a lot of data gathering for the team. When it is time to submit reports for the state, sometimes I can find what I need in the Care Management Dashboards as well as in the CurrentCare Viewer. The Care Management Dashboards is used more regularly by our care team. During their morning meetings, they can confirm who is in the hospital so they can make a plan for that day. By monitoring the Care Management Dashboards, they don’t have to wait until we get a report about the event at a later time. Depending on the client’s treatment plan, we can then be ready with interventions, as appropriate.

Having information on the Care Management Dashboards about CurrentCare enrollment status is also helpful. If we see a client is on the Dashboards and is not in CurrentCare, it prompts us to ask them to enroll. For some clients, we don’t see them more than quarterly. In these situations, we can use information in CurrentCare to get information about their status and what they need. Rather than having to outreach to these patients we can save time if we need to check recent information about their BMI, blood pressure or A1C test results. This is particularly helpful for our community clients.

Integra

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Nurse Care Managers: Jean Taylor, Rebecca Pizzuti, and Barbara Dauber

How did things take place before Care Management Alerts?
Before we had Care Management Alerts, in order to get information about our patients who were going to the hospital, we were dependent on the discharge lists we received from the operating units at the hospitals within the Care New England system (including Kent Hospital, Women and Infants, Memorial and Butler). When our patients were admitted at a facility outside of our network, we would have no information, unless we happened to see something that had been entered into our Electronic Health Record, Epic. Prior to Care Management Alerts, if patients went to other hospitals, such as Landmark, Rhode Island Hospital, St Joseph’s, South County Hospital or Newport, we had no way of knowing. Therefore, we would not know about these instances when our patients may benefit from our care.

How do things take place with Care Management Alerts?
Since we started receiving Care Management Alerts, we are now notified when our patients are admitted to any of the acute care hospitals in Rhode Island. When we learn that a patient is in a facility, we can reach-out to the individual about their care plan and offer assistance. We have Integra Nurse Care Managers immediately in the Emergency Room at Kent, as well as in-house at Memorial and Butler Hospital. When we get a Care Management Alert that one of our patients is in the Emergency Room at one of these facilities, we can call the Nurse Care Manager directly at the hospital and give them an update on the work we are doing with the individual. It is very helpful to have real time communication with the Nurse Care Managers. We can loop the doctor in, if needed, as well.

“Since we started receiving Care Management Alerts, we are now notified when our patients are admitted to any of the acute care hospitals in Rhode Island.”

When our patients go to hospitals that we are not directly associated with, we now have an opportunity to act on and reinforce education and behaviors regarding their health. We can assess them to determine if they may benefit from a visit with a Nurse Practitioner. Additionally, patients aren’t always the best historians, so knowing they are at a hospital, we can reach out to the facility and provide important information to the staff who are treating the patient. Being able to provide this intervention can have a positive impact on the Emergency Room visit. We can then include the Emergency Room visit into our plan.

Sometimes, when we get a Care Management Alert, we follow-up by looking in CurrentCare or CareEverywhere, in Epic. In CurrentCare, we can get the most recent demographics for the patient. With this information, we are often able to contact someone who we otherwise hadn’t been able to reach. Also, receiving the Care Management Alerts from the Skilled Nursing Facilities is really helpful. When we receive a discharge Alert from a Skilled Nursing Facility, we are able to follow-up and ensure that home care was arranged.

Having Care Management Alerts is particularly valuable when working with our High Risk Medicaid population. If we tried to outreach to a Medicaid patient unsuccessfully in the past, knowing they are in the hospital gives us a new opportunity to connect with them. Sometimes a Care Management Alert is the only evidence we have that our critically ill patient is still alive. In some cases, with patients who have limited minute cell phones, we can go for weeks without contact. When we can get this vital information, that they are alive, it is extremely helpful.

One unique situation we had in which Care Management Alerts made a critical difference was with a husband and wife team. We provide care management for both individuals, but the wife has dementia and is more physically disabled. When we were alerted that the husband had gone to the Emergency Room and was hospitalized for a cardiac issue, we were able to immediately contact their family to provide care for the wife. Knowing that the husband was the healthier spouse, we contacted the family right away. This enabled them to make arrangements to help her, because she could not be alone. The family didn’t have to get respite care and were able to take care of her until her husband was well enough to return home.

How does that impact your life/work?
Having Care Management Alerts improves the timeliness with which we can provide therapies to our patients. If we don’t know they have a problem, then there is nothing we can do. If we have knowledge, then we can provide treatment.

“Having Care Management Alerts improves the timeliness with which we can provide therapies to our patients.”

Also, having information from the Alerts helps us to adjust treatment. If we have an established care plan for a patient, going to the Emergency Room is a jumping off point to review their plan and create a new one that would prevent this from happening again. You can’t fix what you don’t know. With Care Management Alerts, we are better able to see what is working and adjust, as needed. Knowing when our patients are in the Emergency Room supports us in providing the most comprehensive care possible. Care Management Alerts are truly critical to what we do!

Rhode Island Primary Care Physicians Corporation (RIPCPC)

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Nurse Care Managers: Sara Marino, Mariana Peterson, Sharon Campbell, Janis Miney, Monique Fleurant, Ann Marie Lonergan, Andrea Lamont, Bobette Chase, Christine Kennedy, Donna Jacques Director of Care Management: Shirley Carter

How did things take place before Care Management Services?
Years ago, when we first started providing care management at RIPCPC, it was very difficult to get timely information about our patients' hospital encounters. Often, we would not get information until two months after an event had occurred. In time, there was improvement in how quickly we would be notified. Rather than waiting two months, the delay was closer to two weeks.

In more recent years, prior to having the Care Management Dashboards, we have been receiving more real time Hospital Alert information, but the data we received was cumbersome to process and was not consistently available for all of our patients. For example, in some cases, we would get 6 or 7 emails regarding transfers and discharge for the same patient. It was often a stream of emails that were not really helpful. The messages had too much information and they would be out of order and piled up. We would waste a lot of time sorting through the messages to determine our patients' current status and needed follow-up.

How do things take place with Care Management tools?
Now that we get information through the Care Management Dashboards, the data we receive about our patients' admissions and discharges from the hospital is significantly more timely and streamlined. Because of this, we don't have that overwhelming feeling of being confronted by numerous emails and still not know where our patients are and what we need to do to help them. We can rely on our Care Management Alerts to keep us informed so we can provide timely interventions and care coordination.

For example, if we have a patient that was in the Emergency Department from midnight to 2 am, we know we will come in to the office that morning and had the alert information right away.

Also, with the Care Management Dashboards we now have additional information that really helps us improve the care we provide and help us work more efficiently:

  • By having timely and reliable admission and discharge information for all our patients, we can be sure to effectively target the needs of each individual in our care. We can ensure they have follow-up appointments scheduled with the right doctors. We can also make sure that they have other specific support and care, depending on the situation. For example, when a patient needs equipment in their home, such as a hospital bed or shower chair, it is better when we are able to get it for them before they come home. When we know what facility the patient is in, we can reach out and have a quick phone call to coordinate care- this is especially critical after a stroke or other health event.
  • Along with knowing when our patients are discharged from an acute care hospital, it's really helpful to know when our patients are admitted to a skilled nursing facility. It's great when we aren't having to make 10 phone calls to find out where our patient is!
  • By having the discharge disposition, we know if our patients are discharge to their home and in need of follow-up or home care. We don't have to "be a spy" and search around the patient record looking for information about what follow-up the patient may need.
  • The discharge disposition also alerts us when out patient has been discharged to hospice care. With this information, we can better coordinate care and stay informed about our patients' status.
  • Having updated demographics is also extremely valuable. In particular, the phone number we get from the Care Management Dashboards is often more updated than what we have in our records. If a patient signed up with one of our doctors 5 years ago, we might have an old phone number on file, but what we get from the dashboards is current. By having this information, we are more reliably able to connect with patients when providing outreach.
  • When managing a team of nurses, data from the Care Management Dashboards is uniquely beneficial. On the Dashboards, we can see how many discharged patients each Nurse Care Manager has. By having this information, we can ensure that follow-up is happening. We can also make sure that individual staff are not getting overwhelmed by their workload.
  • When providing care, we like to know if the person has CurrentCare or not. It helps that we are able to easily see if they are enrolled in CurrentCare through the Care Management Dashboards data we receive. With CurrentCare, we can find more details about a patient's encounters either through viewing CurrentCare information in Epic or through the CurrentCare Viewer. Before we call our patients who are more complex, we can check CurrentCare to find updated information about their medications and additional details about what happened at the hospital.

We particularly appreciate when we receive a discharge disposition informing us that a patient has expired. The immediacy of getting this information is very critical! Hospice does not always inform the Primary Care Provider right away, so when we receive this information, we are able to notify our practice that the patient has passed. This way, we can all provide better communication with the family. It's a real opportunity for us to provide support and help at a crucial time. Because the data from the Care Management Dashboards is so real time, we recently had an occurrence in which a notification was received by the Nurse Care Manager before the patient's chart in our EHR was updated: the Care Management notification beat Epic! Having this information, we were able to call the daughter to say, "I am so sorry for your loss" and "can I do anything?" When members of a family are all patients as a Family Practice, we can provide additional support for the other members of the family and help them through their loss. The patients' families really appreciate learning about grieving support that is available after losing a loved one. Overall, knowing a patient has passed is very important to us so we can give support rather than call and feel bad and out of the loop.

“Now that we get information through the Care Management Dashboards, the data we receive about our patients’ admissions and discharges from the hospital is significantly more timely and streamlined.”

There are many other examples of how the Care Management Dashboards has benefitted our practice and the care we provide. Because the information is so timely, we can initiate informed and immediate outreach. The feedback from our patients has been very positive. In one case, one of our Nurse Care Managers called a gentleman who had been recently discharged. He commented, "I just picked up my scripts. I just got home an hour ago!" For another complex patient who had recently returned home from the hospital, the Nurse Care Manager was able to call and touch base right away. While he was too tired to talk about his medications that afternoon, she was able to make sure he was planning to bring his medication bottles to his appointment with his Primary Care Provider the next day. The Nurse Care Manager was able to confirm he had his appointment scheduled and ensure that did not have any other immediate needs.

How does that impact your life/work?

“We feel that having information from Care Management Services is really the ultimate in care.”

The impact of this technology and data is truly awesome. It is like a "ray of sunshine" for us and it helps for us to provide better care! With the Care Management Dashboards, our work has become much more streamlined because the data provided to us is much less confusing than the sources we were working with previously. We have been able to cut down on searching for information and we save time. Though having information from Care Management Services, we have gotten back at least 2 hours a week (maybe even a day!) of time. It is hours of our time- not minutes - that we are saving. Being able to get this critical information so easily has really put a lot of sanity in our lives!

We feel that having information from Care Management Services is really the ultimate in care. It is a godsend that truly helps us be more effective in the work we do. We are able to provide timelier follow-up and help our patients feel really cared about. It is so REAL TIME and quick! Sometimes, I can go in person to visit a patient when they are admitted to a hospital. One of our favorite older patients had gone in to the hospital with an injury. When I arrived for a visit, he was really happy to see me!

Thundermist Health Center

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Names: Gloria Rose, RN; Marisa Smith, RN, CDOE; Melissa Jesuino, RN; Amanda Fontaine, RN; Vera Whalen, RN, CDOE; Cheryl Cook, RN; Michelle Gamache, RN; Lania Rodgers, RN, CDOE; Jennifer Wagner, RN; Emma Romano, RN; Matt Saraniti, RN

How did things take place before Care Management Services?

As the Nurse Care Management Team at Thundermist Health Center, an important element of our work is to provide support for our patients when they go to the hospital. Particularly for patients who have multiple, chronic illnesses and are at high risk, it is critical that we provide outreach and timely follow-up. In order to do this, we rely on notifications from hospitals throughout our region. When we receive these notifications, the data gets processed by our document management team who then sends notices to our Care Management team using our Electronic Health Record (EHR). Once we have this information, we then need to monitor for discharges so we can take action and engage with our patients to provide care, including education and scheduling follow-up appointments, as needed.

Prior to using the Care Management Dashboard, we were not always notified by the hospitals when our patients were discharged. Also, we would often have to make multiple phone calls to get critical information that we need to provide follow-up on hospital admissions. For some hospitals, we have reliable relationships and contacts with the Care Management Departments, so with these we typically have productive interactions. But, with other hospitals, sometimes we would not have a contact that we could follow-up with. In these cases, we would maybe get a document later on saying the patient had been discharged. We would often end up playing phone tag and we were challenged by the fact that would have a delay in our receipt of the requested data. Overall, the work we were doing to engage in this level of care coordination was time consuming.

How do things take place with Care management Tools?

Now, using the Care Management Dashboard, we have a place we can go to get reliable updates about our patients’ admissions and discharges from hospitals all over the state. Typically, each morning we sign in to the Dashboard and filter on the providers we work with to get our specific patient lists. Then we look at the related information that has already been documented in our EHR and update our records to note when patients are still admitted or when they have been discharged. Using the data from the Dashboard in this way, we are better able to track current hospitalizations for our patients.

As we were the first healthcare organization in Rhode Island to pilot the Care Management Dashboard, we started by having specific sites utilize this tool. We found that the sites using the Dashboard developed a much more streamlined process than the old process of making phone calls. When our Director of Community Care Management, Gloria Rose, spread this established Care Management Dashboard workflow, the tool quickly became integral to the work at all sites. As one Nurse Care Manager describes, “when I first started using it, I was like, wow! There are certain patients who are ‘frequent fliers.’ Once I see them on the Dashboard I reach out right away and call the family. Then I can let the provider know right away, too. I am able to keep mental notes and document in the EHR so I can be ready when they are discharged.”

Our teams finds it to be very helpful that we can see where each patient is and even the room they are in when they are admitted to a hospital. For example, when we see they are in a specific room on the fourth floor and we can talk to the nurse in the unit and coordinate care. Also, for special cases, with this information, we can go to the hospital in person or send a member of our community health team to see the patient. When we do this, we typically call the unit ahead of time and let them know that we are going to come in to visit a patient. For our patients receiving Medication Assisted Treatment and those who are high risk, it is great to have this opportunity to engage with patients and make a face to face connection. Particularly for our patients who we know have no family there to support them, being able to provide this outreach for them can be very important.

Our workflow for following patients who are in the Emergency Department (ED) is different from our inpatient admission tracking processes. For these patients, our Nurse Care Managers use the Care Management Dashboard to check for individuals who we are specifically monitoring and who are at risk. For patients who would benefit from outreach, we will often engage our community health team. As it is often harder for us get data regarding ED visits, it’s very helpful for us to use the Dashboard to track this utilization. We are also able to follow this data to find if there are any possible hospital admissions that may occur following the ED visit. Being alerted to this information can really be beneficial for the care we are able to provide. For example, recently, a patient who was being tested for memory issues went to the ED. When we saw this individual on our Dashboard, we were able to call the hospital to coordinate care and make sure they did specific tests based on this individual’s status. This type of engagement among clinical teams can lead to significantly better outcomes for our patients.

How does that impact your life/work?

Having the Care Management Dashboard makes things a lot easier and a lot more organized for our Care Management Team at Thundermist. Prior to using this tool, our days involved significantly more phone calls and last minute scrambling to provide outreach. In the past, patients often wouldn’t call us post-discharge. Given this, sometimes it would be more than a week before we would know that they had been hospitalized. Now, our processes are more efficient. We have a heads-up right away and are able to proactively check their medications etc. and outreach to them, as needed.

By starting out the day by checking the Dashboard, it sets the tone as far as what we need get done during that shift. Generally, we avoid booking anything in the first slot of the day so we are able to use this time to check the Dashboard and assess what follow-up efforts to expect. If a patient gets booked during that time, it really changes the cadence of the day when we are not able to have this time to get organized. Throughout the day, whenever we have extra time we will pop back on the Dashboard to check the status of certain patients and monitor for new admissions.

We have many examples of how having this tool has made a significant impact in our practice. In one case, a patient that had been incarcerated overdosed. We knew this individual was homeless and we were able to make arrangements and get him placement right into a sober house as soon as he was discharged. In another example, when a patient expired at the hospital, we were able to see this information on the Dashboard. It was very helpful that we were able to avoid calling this person’s home to book a post-hospital follow-up appointment. Having this information can avoid an awkward conversation with family members. Overall, by having the Care Management Dashboard, we are more organized and able to provide better care for our patients.