One of the larger hurdles LTPAC providers face is ensuring that patients follow their treatment plans post-discharge so they don’t end up back in the hospital battling their chronic conditions.

By Pam McDonald

Most doctors and hospital administrators are well aware that the federal government provides incentives for the adoption of certified electronic health record (EHR) technology. Long-term and post-acute care providers anticipate these inducements will be extended to them as well.

As the largest single payer of health and long-term care in the United States – primarily through the Centers for Medicare and Medicaid Services (CMS) – the federal government has considerable interest in containing costs. And lawmakers also believe EHRs can promote better clinical outcomes as well as improve safety for patients.

CareCommunity™ Will Save Federal Dollars

MatrixCare® (a Senior Housing Forum partner) is the largest provider of integrated software that enables those providing LTPAC to efficiently track and manage patient and resident care along with administrative tasks. Currently MatrixCare® is introducing its powerful new EHR platform, CareCommunity™, into the healthcare arena.

CareCommunity™ is secure web-based technology that collects, aggregates, and displays health, EHR, and personal information for seniors as a robust and useful summary of an individual’s care delivery clinical experiences over time. Or, what MatrixCare®’s Senior Product Manager Maria Moen calls “a true longitudinal health record.”

Better Monitoring of After Hospital Care

With its innovative, social networking-groupware that coordinates and informs teams of caregivers treating patients or customers, CareCommunity™ offers what Maria identifies as its greatest benefit –– reducing federal long-term care spending.

First, she notes, “One of the larger hurdles LTPAC providers face is ensuring that patients follow their treatment plans post-discharge so they don’t end up back in the hospital battling their chronic conditions.

“Once a senior [or any patient] leaves a physician’s office or discharges from a hospital or SNF,” Maria says, “there has been little the care team can do to monitor and ensure compliance with treatment or address barriers that prevent adherence with specific components of aftercare,” she says.

Reducing Re-hospitalization

“Re-hospitalizations account for significant costs for Medicare and Medicaid patients, so reducing those costs has significant value to the government. Also, decreasing charges for duplicate tests ordered due to lack of information about existing results is another area of opportunity to lower federal spending.”

Maria believes that a key to lessening re-hospitalization has to be “more deep-seated than existing patient-provider face-to-face interactions.” She says, “CareCommunity™ allows physicians and care teams to manage their entire patient population across provider- and care-setting boundaries through a single access point.”

She continues, “This makes it easier to monitor each resident’s care and progress toward their treatment plan, including patients who are discharged from LTPAC settings who need monitoring to avoid re-hospitalization within that critical 30-day period post-discharge.”

Improving Medication Management Across Care Settings

Maria also points to studies that have shown how complex medication management is as seniors move across care settings. She says, “Medication management from a hospital to a SNF or senior living community can be a particularly tricky transition point. It requires full visibility, close oversight, and monitoring. Few care tracking EHR platforms provide the visibility needed.”

And, she notes, “When transitions are mismanaged, we can find the senior back in the hospital due to medication challenges. Perhaps prescriptions didn’t/couldn’t get filled, or some medication didn’t leap the chasm from one care setting to another, which exacerbates health conditions.”

There also might have been undocumented medication in patients’ homes or care settings to which they return from the hospital that were contraindicated with the newly prescribed medication regime.

CareCommunity™ has a family and patient engagement capability that creates the opportunity to know of and incorporate into medication planning supplements, herbals and over-the-counter medication that are not captured elsewhere, except within CareCommunity™. This is a key differentiator for health care settings the senior is moving through and for the providers who are managing the care of the senior.

Easing Communication Among the Entire Healthcare Team

In a mobile platform, CareCommunity™ provides the tools needed to facilitate better monitoring and visibility, more frequent follow-up, enhanced social support as well as connectedness to support systems, and improved care coordination for high-risk patients. Patients with lower risks can benefit from automated notifications about their vital signs, regular screenings and medication.

Providers using CareCommunity™ offer their patients greater ease and access in communicating with their physicians and entire care management team. This may facilitate health care consumers more successfully following action paths that lead to healthier lifestyles and fewer, as well as lower cost, medical care encounters billed to payers such as the feds.

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