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The Path to More Referrals Just Got Shorter

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By Susan Saldibar

Let’s talk about the pipedream of integrated health records that are centralized and accessible by physicians, pharmacies, post-acute providers, and residents.

Is “pipedream” too strong a word? In fairness, this has been a goal for several years now. There is no lack of talking about systems that share information, store it centrally, and create one portal instead of many. Yet most post-acute care providers, such as skilled nursing, remain slow to act.

There are probably plenty of good reasons why, but after several years of technology advances wouldn’t you think this piece would be pretty much nailed by now? Especially given the steady pressure being applied by CMS. Yet, today we still live in a world where physicians have to log on to several portals to access a resident’s medical records and track progress. Hospitals still sit like islands disconnected from post-acute care providers, pharmacies, and physicians.

Skilled nursing facilities are leaving a huge opportunity on the table.

Continuing to remain so far behind the innovation curve may be risky for skilled nursing, as CMS continues to adapt its reimbursement models in ways that cry out for automation and integration of systems.

Electronic Health Records (EHR) software is one tool that moves towards tighter integration and, by most accounts, is already leading to better care. And, the growing consensus is that those post-acute care providers who can make integration easier for physicians and hospitals will have an edge in forming partnerships, or at least getting more referrals, as CMS tightens its belt and the rules of engagement for all providers.

Turning more acute providers and physicians into partners where everyone wins.

I spoke recently with Kelly Keefe, Senior Product Manager for MatrixCare (a Senior Housing Forum partner). They have taken a proactive stance and are out to equip clients with tools to help get them get out in front and jump ahead of others who take a “wait and see” posture. Their CareCommunity is a great example of that. It is the ultimate coordination platform that works with a variety of EHRs and gives everyone along the care supply chain a full view of the patient; including the care regimen, medications, health history, and much more.

After speaking with Kelly, two key aspects of CareCommunity really stand out in terms of making a direct impact on care and communication for post-acute care providers:

  • Single platform with a single login. This is huge for physicians, communities, and residents. No more logging into separate systems and having to reconcile information from each.

  • Records that follow the resident through the continuum of care; from acute care – post-acute care – pharmacy and back around again. Things like blood-sugar levels, weight, medications and other conditions are updated in a single place. “Think about the increase in accuracy and how that impacts the quality of care and outcomes,” says Kelly. “It makes it so much easier on those charged with following up with a resident to avoid rehospitalizations.”  

Can platforms like CareCommunity help resolve the occupancy challenges?

And here’s another point that Kelly makes. It doesn’t take a lot of insight to realize that acute care providers and physicians will gravitate towards those senior care providers who make it easier for them to improve outcomes for patients. This is also now true for assisted living communities, by the way, as many take on more post-acute care residents.

So what could all this do for occupancy? How could it impact relationships throughout the care cycle?

The impact can be significant, Kelly tells me. “Senior living providers worry about occupancy rates. You can help ensure higher occupancy by being a good downstream partner to other organizations,” she says. “In this era in which you are encouraged financially to make length of stays shorter, solutions like CareCommunity can help provide a higher level of care to help ensure that residents don’t go back to the hospital.”


You can read more about CareCommunity here.

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