How St. Joseph's Health and CareOne bridged the gap between acute and post-acute care: 2 leaders discuss

Healthcare organizations are increasingly leveraging data analytics to better collaborate with post-acute networks to improve patient care and reduce total costs. 

During Becker's Post-Acute Virtual Event session "Care Coordination Panel Discussion: Forging a Successful Partnership Through Data Analytics," two clinical leaders discussed how hospitals and post-acute providers can develop a mutually beneficial partnership. Real Time Medical Systems sponsored the panel, and Phyllis Wojtusik, RN, Real Time's executive vice president of health systems, served as moderator. 

Panelists were: 

  • Helen Ali, RN, manager of clinical transformation at Paterson, N.J.-based St. Joseph's Health  
  • Margaret Nolan, vice president of clinical program development at Fort Lee, N.J.-based CareOne Management 

Below is a five-point summary of the discussion: 

1. Ms. Ali and Ms. Nolan discussed how their organizations successfully bridged the gap between acute and post-acute care, and how their collaboration has improved patient care and reduced total cost of care. Ms. Nolan said much of the organizations' success is dependent on effective care coordination, made possible by Real Time’s interventional analytics tools.  

2. Organizations should collect both patient and network data when collaborating across post-acute and acute care. Real Time delivers patient level data such as vital signs, clinical trends, orders and clinical alerts. Real Time also provides a facility overview and network view of performance metrics such as readmission rates, length of stay, and performance by case type.

3. Interfacility data transparency can help systems understand what is happening at the patient-level during a post-acute stay. Leveraging both patient-level data and network-level data can open the lines of communication between care teams. This open communication enables the opportunity to intervene in care to improve patient outcomes. Ms. Ali and Ms. Nolan noted that the data transparency helped provide a true clinical picture, thereby enabling mutual trust while expediting transitions of care in the best interest of achieving patient goals. 

4. Collaboration between organizations can also reduce readmissions via data transparency. Care teams receiving live clinical alerts when a patient's condition changes can work together to solve problems. Using data to stratify patients by risk level allows organizations to focus on patients who are higher readmission risks. Leveraging Real Time's interventional analytics also allows teams to work proactively and assess if certain care plans are working and if improvements to the plan are effective.

5. Interventional analytics have helped the teams at St. Joseph's and CareOne better collaborate around patient care. By obtaining live access to CareOne's EHR data, St. Joseph's can better partner with the post-acute center to reduce total cost of care via lower readmissions and length of stay. Upon patient admission to CareOne, the hospital and post-acute team set goals and work toward those goals together. They are no longer siloed entities, but instead true partners working toward shared goals, Ms. Ali explained, saying, "It's formed a stronger collaboration, and also a smoother transition for our patients." 

Click here to view the full event.

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