Solving the post-acute care mystery — Dr. Lissy Hu on the benefits of technology company CarePort

Lissy Hu, MD, is the CEO and founder of CarePort Health, a software company which matches patients in need of post-acute care to post-acute care organizations.

Dr. Hu spoke with Becker's Hospital Review on the importance of post-acute care management and how CarePort improves outcomes.

Question: How is digital health technology improving post-acute operations and patient care management?

Dr. Lissy Hu: For decades, post-acute care has not been viewed as a major priority within the healthcare system; as a result, the processes for transitioning patients and following them post-discharge are highly inefficient. Patients being discharged are asked to select a post-acute provider, such as a nursing home or home health agency, from a paper list with provider names and addresses. No information about the quality of these providers, which can be highly variable, is given. This process is not only blind for patients, but also for providers. Physicians, care coordinators and even caregivers have limited visibility into how a patient is cared for in a post-acute setting.

New technologies bring much needed transparency to post-acute care. With advanced tracking and analytics capabilities, providers and payers can — for the first time — grasp the real-time status of their patients' health, provide sound advice and empower patients to take control of a critical part of their healthcare journey. Next-generation technology guides the post-acute journey by:

  • Enabling patients to select the post-acute provider that best fits their needs
  • Tracking patients in real time across multiple settings of care
  • Intervening when the patient's journey deviates from the expected course
  • Assessing the performance of post-acute providers
  • Managing post-acute cost and quality outcomes to benchmarks

The need to manage patients across post-acute settings is even more pressing with the shift to value-based payment models, making this type of technology extremely high impact.

Q: What should more organizations be doing in terms of technology adaptation that they currently aren't? What are the barriers for adaptation?

LH: Post-acute care processes are currently paper and phone based. Organizations can realize significant returns on investment by moving to technology solutions that both support appropriate post-acute facility selection and post-discharge tracking.

Let me address facility selection first. In [the] current day, patients are choosing post-acute providers based on ZIP code rather than clinical appropriateness. Hospital case managers send the referrals to the providers, who may not even be able to care for the patient. For example, a dialysis patient might unknowingly select a provider that doesn't provide dialysis on site. Adopting a technology solution, like a search engine, solves this problem. In a few seconds, case managers can search for post-acute providers based on a patient's insurance, clinical services and quality scores and share with patients and their [families] providers that truly meet a patient's needs.  

When a patient leaves the hospital, they are at their most vulnerable. Currently, tracking of that patient occurs primarily through phone calls. You can imagine how cumbersome this is, with voicemails and lots of back-and-forth between case managers and post-acute providers. A technology solution like CarePort can solve the problem. Our platform connects to post-acute providers' EHRs, retrieves the relevant patient information and sends it back to the hospital care coordinator who is managing that patient across the episode. With automated, real-time information, no patient slips through the cracks. No unnecessary phone calls are required.

One barrier to adoption that we initially encountered was skepticism about our ability to connect with post-acute providers. Many hospitals administrators believed that all nursing homes operate on pen and paper, when in fact these facilities have their own EHRs. I'm excited to share that as of January 2018, CarePort can connect with over 90 percent of the nursing homes in the U.S.

Q: How does the technology benefit a community? 

LH: CarePort provides hospitals, ACOs and payers with three solutions: CarePort Guide, CarePort Connect and CarePort Insight. These solutions help guide patients to quality post-acute care, track the care they're receiving and collect information about patient and provider outcomes.

CarePort enables payers and providers to follow their patients from A to B and track their progress. On a system level, our analytical capabilities allow our customers to capture valuable data and insight into how post-acute providers are performing to drive continuous improvement. On a patient level, our analytics show in real time when a patient is deviating from their expected post-acute care course so that their care coordinator can intervene in a timely manner.

The common thread across CarePort's platform is providing transparency for all parties involved in post-acute care. In return, it helps to improve individual patient outcomes and provide broader population health benefits.

Q: What's something you feel the digital health field should be talking about but isn't? 

LH: There is no shortage of innovation within the industry, but most innovation has been focused on hospitals and physician offices. We are addressing the post-acute space. While critical, post-acute is just one part of the continuum. To really succeed with value-based care and population health programs, care coordinators need to track patients across all settings. Beyond the post-acute space, we are now also tracking patients who return to the emergency department or the hospital. Our vision is to ultimately provide full visibility across the entire continuum, guiding the journey no matter where the patient goes.

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Solving the post-acute care mystery — Dr. Lissy Hu on the benefits of technology company CarePort
Lissy Hu, MD, is the CEO and founder of CarePort Health, a software company which matches patients in need of post-acute care to post-acute care organizations.
Dr. Hu spoke with Becker's Hospital Review on the importance of post-acute care management and how CarePort improves outcomes.
Question: How is digital health technology improving post-acute operations and patient care management?
Dr. Lissy Hu: For decades, post-acute care has not been viewed as a major priority within the healthcare system; as a result, the processes for transitioning patients and following them post-discharge are highly inefficient. Patients being discharged are asked to select a post-acute provider, such as a nursing home or home health agency, from a paper list with provider names and addresses. No information about the quality of these providers, which can be highly variable, is given. This process is not only blind for patients, but also for providers. Physicians, care coordinators and even caregivers have limited visibility into how a patient is cared for in a post-acute setting.
New technologies bring much needed transparency to post-acute care. With advanced tracking and analytics capabilities, providers and payers can — for the first time — grasp the real-time status of their patients' health, provide sound advice and empower patients to take control of a critical part of their healthcare journey. Next-generation technology guides the post-acute journey by:
Enabling patients to select the post-acute provider that best fits their needs
Tracking patients in real time across multiple settings of care
Intervening when the patient's journey deviates from the expected course
Assessing the performance of post-acute providers
Managing post-acute cost and quality outcomes to benchmarks

The need to manage patients across post-acute settings is even more pressing with the shift to value-based payment models, making this type of technology extremely high impact.
Q: What should more organizations be doing in terms of technology adaptation that they currently aren't? What are the barriers for adaptation?
LH: Post-acute care processes are currently paper and phone based. Organizations can realize significant returns on investment by moving to technology solutions that both support appropriate post-acute facility selection and post-discharge tracking.
Let me address facility selection first. In [the] current day, patients are choosing post-acute providers based on ZIP code rather than clinical appropriateness. Hospital case managers send the referrals to the providers, who may not even be able to care for the patient. For example, a dialysis patient might unknowingly select a provider that doesn't provide dialysis on site. Adopting a technology solution, like a search engine, solves this problem. In a few seconds, case managers can search for post-acute providers based on a patient's insurance, clinical services and quality scores and share with patients and their [families] providers that truly meet a patient's needs.
When a patient leaves the hospital, they are at their most vulnerable. Currently, tracking of that patient occurs primarily through phone calls. You can imagine how cumbersome this is, with voicemails and lots of back-and-forth between case managers and post-acute providers. A technology solution like CarePort can solve the problem. Our platform connects to post-acute providers' EHRs, retrieves the relevant patient information and sends it back to the hospital care coordinator who is managing that patient across the episode. With automated, real-time information, no patient slips through the cracks. No unnecessary phone calls are required.
One barrier to adoption that we initially encountered was skepticism about our ability to connect with post-acute providers. Many hospitals administrators believed that all nursing homes operate on pen and paper, when in fact these facilities have their own EHRs. I'm excited to share that as of January 2018, CarePort can connect with over 90 percent of the nursing homes in the U.S.
Q: How does the technology benefit a community?
LH: CarePort provides hospitals, ACOs and payers with three solutions: CarePort Guide, CarePort Connect and CarePort Insight. These solutions help guide patients to quality post-acute care, track the care they're receiving and collect information about patient and provider outcomes.
CarePort enables payers and providers to follow their patients from A to B and track their progress. On a system level, our analytical capabilities allow our customers to capture valuable data and insight into how post-acute providers are performing to drive continuous improvement. On a patient level, our analytics show in real time when a patient is deviating from their expected post-acute care course so that their care coordinator can intervene in a timely manner.
The common thread across CarePort's platform is providing transparency for all parties involved in post-acute care. In return, it helps to improve individual patient outcomes and provide broader population health benefits.
Q: What's something you feel the digital health field should be talking about but isn't?
LH: There is no shortage of innovation within the industry, but most innovation has been focused on hospitals and physician offices. We are addressing the post-acute space. While critical, post-acute is just one part of the continuum. To really succeed with value-based care and population health programs, care coordinators need to track patients across all settings. Beyond the post-acute space, we are now also tracking patients who return to the emergency department or the hospital. Our vision is to ultimately provide full visibility across the entire continuum, guiding the journey no matter where the patient goes.

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