Technology is helping prevent readmissions, but integration across the care continuum remains a pressing goal, experts say

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As data sets increase for post-acute care, so will the need for standardization and the push for skilled nursing facilities to be connected with other health entities, experts said at a health information technology summit Tuesday.

For example, skilled nursing facilities seeking greater connectivity might want to hire community health coaches to reduce hospital readmissions, and empower employees with mobile technology, one physician said during the 2014 Long-Term and Post-Acute Care Health IT Summit in Baltimore.

His Care at Hand model involves non-clinical healthcare workers, such as a community coach, using technology at the point of care, with an application that is directed at a nurse care manager, explained Andrey Ostrovsky, M.D., Care at Hand co-founder and chief executive officer. The community-based coach fills out a patient survey with questions based on the Coleman transition of care model. The coach can spend more time than a more highly paid nurse in getting the patient's history and spotting potential challenges in community reintegration. The tool also gives data pinpointing those at high-risk for readmissions, which Ostrovsky called “hot spotters.”

“Every software technology should be giving you a list of hot spotters,” he advised. Data are “the great equalizers” among care providers, he added. In many discussions of care, there are “bow-tie wearing Harvard docs and community nurses,” he said, and “data strips the bow tie off.”

Elder Services of Merrimack Valley saw a 40% reduction in hospital readmissions in 30-day hospital readmissions by using Care at Hand, saving more than $565,000 over six months, according to a recent case study. While the product hasn't been geared toward skilled nursing facilities, one SNF under a bundled payment plan embraced it as a tool to reduce readmissions and hired the coaches themselves, Ostrovsky told McKnight's.

The long-term care industry is “really having to look at standardization and coordination,” said Anita Yuskauskas, Ph.D., technical director for HCBS Quality within the Centers for Medicare & Medicaid Services. She was discussing the $62 million initiative known as TEFT (Demonstration Grant for Testing Experience and Functional Assessment Tools in Community-Based Long Term Services and Supports). The program is meant to look at quality measurement tools and demonstrate e-health in Medicaid long-term services and support services.

TEFT awards were made in April for nine states — Arizona, Colorado, Connecticut, Georgia, Kentucky, Louisiana, Maryland, Minnesota and New Hampshire — which are working on their plans, she said.

One challenge to getting data flowing across settings is motivating hospitals to work with long-term care settings, noted Reliant Medical Group's Larry Garber, M.D.

“Hospitals are really focused on ICD-10 and Meaningful Use,” he said. “It's a focus that is not necessarily what we need in long-term and post-acute care.”

Vendors and providers might find help in the CIO Consortium & Nurse Executive Council's white paper, “Electronic Health Record Solutions LTPAC Providers Need Today," which was released last year. In a session on what CIOs and nurses have learned since the paper's release, panelists spoke about how the paper can lead to a solution, especially in connection with garnering clinical input.

The paper “has opened dialogue on the clinician side and allowed us to continue a more positive dialogue,” said Debbie Jones, RN, LNHA, the CEO of New Beginnings Care. Some vendors have seen the paper as a critique, but others have embraced it and used it as a motivator, Jones and other panelists noted. Providers need help from vendors to achieve interoperability and allow clinicians to have more control over viewing data, Jones said.

The bottom line is, technology needs to be easy for clinicians, said panelist Jillene N. Snow, RN, BSN, MBA, CHCC, the senior vice president of compliance and clinical information at Ethica Health and Retirement Communities.

“We forget that at the end of the day, it's people taking care of people,” she said. “Nurses and nursing assistants want to take care of people. Technology has to be easy, and we try to help making technology their friend.”

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