Meeting care coordination challenges during COVID-19 and beyond

In a recent Q&A session, CarePort Health CEO and founder Lissy Hu, M.D., discussed the value of clinical data stored in EHRs, within the context of the ongoing COVID-19 global pandemic. Real-time, cross-continuum data empowers clinicians, researchers and government agencies to anticipate care needs during a time when contextual patient information is critically needed.

  • Can you provide an overview of CarePort? Who are your customers and how do you support them in achieving improved care coordination?

CarePort is a market leader in care coordination, with our platform serving as an integral component of hospital processes for the past 15 years. CarePort’s solutions enhance patient outcomes and control total cost of care by streamlining care transitions, guiding patients across the continuum to high-quality providers and tracking their status post-discharge in real-time.

Our customers include hospitals and health systems, physician groups, ACOs and post-acute care providers across the US – more than 1,000 hospitals and 180,000 post-acute care facilities in 43 states use our platform to coordinate care. The CarePort platform ensures all these stakeholders have access to actionable information and are tied into the same communication loop as patients move between different levels of care.

We help our clients achieve success with a host of care coordination activities – from traditional discharge planning and utilization management to post-acute provider network management, to success in value-based programs, emergency department optimization and quality improvement programs on the payer side. 

  • How has care coordination changed in light of COVID-19, and what does CarePort do to help address the pandemic?

Care coordination challenges are magnified during COVID-19, and the pandemic has highlighted the interdependence of providers across the continuum. Hospitals and post-acute providers have needed to communicate in near real-time on a variety of time-sensitive issues to ensure the safety of patients and staff – including the ability to accept COVID-19 positive patients, bed availability and patient test results.

To help its acute and post-acute partners streamline the hospital discharge process, CarePort implemented COVID-19-specific product features to foster safe patient transitions from the hospital to the appropriate post-acute site. Using the CarePort platform, hospitals can proactively communicate patients’ COVID-19 testing status to post-acute providers, both pre- and post-discharge. As a result small but impactful changes made within the CarePort platform, post-acute providers are able to take the necessary measures to protect staff and patients, as well as manage the use of personal protective equipment.

Even early on in the pandemic, as post-acute care providers stopped allowing visitors to their facilities, case managers and discharge planners started to rely more than ever on real-time electronic communication. When a patient transitions from a hospital to a nursing home, a patient or family member typically tours facilities to determine where the patient will transition. During COVID-19, this has to be done online or it won’t happen. We have seen significant adoption of our technology that shares nursing home information virtually, through text or email, so patients and their families can go on virtual tours and see photos.

  • What does the need for interoperability look like, as so much more information is passing between these systems?

COVID-19 has highlighted the need for interoperability and communication between providers to ensure the best possible care for patients. We’ll hopefully continue to see a flattening of the curve, but we have to consider the possibility of a second wave and how to prepare for it. Interoperability can help with that.

Folks are already thinking about interoperability. Serendipitously, CMS has prioritized communication between hospitals, physician groups and post-acute care providers within the Interoperability and Patient Access Final Rule. As part of the final rule’s new Conditions of Participation, hospitals are required to share real-time information and notifications when patients are hospitalized, transferred or discharged. Many people didn’t think post-acute care providers would be included in the rule, but it makes a lot of sense.

Given everything we’re seeing – with outbreaks in nursing homes and how vulnerable those populations are – there’s a definite need for patients to have safe recovery settings like nursing homes or at home with home health care. The ability to communicate seamlessly among hospitals, physician groups and post-acute care providers is essential to providing safe, coordinated care in the coming months.

  • While you’ve been helping these providers communicate and building these connections, you’ve been reporting on the aggregated patient data that feeds into the CarePort platform. What are some insights you’ve found from this data to help manage COVID-19 cases?

The CarePort platform is built to track patients across a variety of care settings. We connect with hospitals in different geographies – rural, urban and suburban – that are different sizes and use different EHRs. The post-acute care side – skilled nursing facilities and home health – is just as diverse. When COVID-19 hit, we quickly realized that we would see tens of thousands of COVID-19 patients pass through our platform.  

As far as I’m aware, a real-time dataset that spans so many different systems, geographies and provider types isn’t available anywhere else at this point. It’s not only unique, it’s a public health need. We were able to see on an aggregated basis what happened to these COVID-19 patients outside of a single institution. We started to see patterns, and the types of patients at risk for severe COVID-19 disease. In our reports, we aggregated this data so that hospitals, health departments and post-acute care providers were more informed when trying to manage COVID-19 patient surges.

Something we discovered early on was that one in 10 severe COVID-19 cases were in middle-aged patients. At that time, there had been a lot of discussion that COVID-19 only affected the elderly population, while our data showed that COVID-19 actually impacted many age groups. Those are helpful insights as clinicians and non-clinical hospital staff are managing COVID-19. Our data and the risk factors that it uncovered opened a lot of eyes into managing and stratifying risk for these different patients who were coming in for respiratory symptoms who were susceptible to COVID-19.

We also have information on the post-acute side. I talked about trends we saw early on, but now we’re also thinking about the recovery period for COVID-19 patients, and what will happen with all of the patients who have been hospitalized. Because so many hospitals and post-acute care providers use our systems to transition out of the hospital into post-acute recovery settings, we want an early indication of how many recovery settings – nursing homes and others – are able to care for COVID-19 patients.

In our dataset, we looked at over 9,000 nursing homes – which is more than half of the total nursing homes in the US – and found that only 11% can care for COVID-19-positive patients. That points to a capacity issue. Where can these COVID-19 patients, who fortunately survived the disease, recover safely? If there are capacity issues on the nursing home side, what other settings of care can we build, whether with home health or COVID-19-specific facilities? These are the considerations that providers across the care continuum, including hospitals and post-acute care facilities, need to keep in mind over the coming months.

  • How can your insights help us manage care beyond COVID-19?

Even before COVID-19, hospitals and health systems have used the CarePort platform to track patients across care settings. We offer enhanced visibility into patient readmissions not only at their own hospitals, but also at other hospitals in the area – offering a better sense of real readmission rates.

Our platform is also very flexible. Customers use it for patients with chronic conditions, such as those managing diabetes or COPD. They also use it to look at specific risk pools or payer types, ACOs, bundles, and also patients in specific settings – like what happens to all patients who go to certain nursing homes. We built the platform this way because we know hospitals need that customization when they’re managing different patient populations. We want to support their care coordination and value-based programs.   

  • Based on these insights, what advice do you have for hospitals and post-acute care providers moving forward?

There’s been a lot of conversation about the new normal – what healthcare will look like and how providers will deliver care – as we move past the first COVID-19 surge. Much of the focus has been on telemedicine as the best way to deliver care in a post-COVID-19 world. Because of this, on both the acute and post-acute side, we’ll continue to see the need for increased communication and transparency.

Even pre-COVID-19, our platform was used by hospitals and post-acute care providers to collaborate and communicate with one another in real time. We’ll see more of this because of the nature of healthcare delivery, the need for much of this communication to move to an electronic platform. We’ll also see much more virtualization of care, even in the way we interact with family members, and continue using our digital tools for sharing information with patients and families.

I also think, and hope, that just because we start to deliver care in virtual settings and there are fewer face-to-face interactions between patients and providers – and between providers themselves – that care doesn’t become more siloed. It’s critical that we have regulations like CMS’s Interoperability and Patient Access Final Rule, and tools that supports our clients in adhering to such regulations.  Real-time information sharing via patient event notifications are essential to coordinate care in this new normal.


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