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June 12, 2018

Four Questions Series: Mary Niemczura, Post-Acute Care Coordinator, Cone Health/Triad HealthCare Network

Triad HealthCare Network (THN), headquartered in Greensboro, NC, is a physician-led, knowledge-based, and care-focused organization that aids member providers in giving exceptional care to patients and its community.

For this installation in our Four Questions Series, we sat down with Mary Niemczura, a post-acute care coordinator at THN. Mary’s role is to monitor and follow up with high-risk patients, as well as to assist with discharges.

1. Can you tell us about some of the care coordination challenges your organization has faced in the last few years?

One of the biggest challenges we have faced at THN has been around patients who are admitted to post-acute care facilities. Before implementing PatientPing, we had no way of monitoring patients once they were admitted to skilled nursing facilities (SNFs). It was as if the patients disappeared off of our radar completely until we were notified of their discharge once they followed up with their PCP. We relied heavily on the SNFs to relay patient events back over to us, but this was not always top of mind for them. As a result, patient events fell through the cracks. We also had no way to monitor patients who were affiliated with ACOs. These gaps were extremely challenging as we looked to coordinate patient care. 

2. How have you overcome these challenges?

Getting connected with PatientPing has helped us monitor patients as they transition across different care settings. With PatientPing, we are now notified whenever patients are discharged to SNFs, allowing us to contact the patient or the SNF to implement our transition of care program. I am also able to collaborate with my team members by keeping them updated when one of their engaged patients is admitted to or discharged from a SNF. This lets them know when it is appropriate to reach out to patients with care plans.

3. How has PatientPing helped you achieve your goals?

For us, PatientPing has opened the door to our managed patients. We now have visibility while patients are both transitioning and receiving care in post-acute settings, and we soon hope to branch out and use PatientPing for our ED and inpatient liaison staff in order to monitor our THN patients. The PatientPing platform is extremely intuitive and its updates only get better and better.

4. Can you tell us about a time when PatientPing helped you help a patient?

I use PatientPing daily to help identify patients in SNFs who are eligible for our chronic disease case management program. A few weeks ago, a non-assigned SNF called me directly regarding a patient that they had admitted who faced numerous medical and socioeconomic issues. Through PatientPing, I was able to verify that the patient was on our roster, and inform the THN social worker. The social worker then drove out to the SNF to work with the staff directly, and help facilitate the patient’s safe discharge home.

Thanks so much, Mary! Did you miss a previous Four Questions blog? Find them all here or sign up below to receive new posts direct to your inbox.

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Tagged: Four Questions, Care Coordination, Healthcare Providers, healthcare, post-acute care, accountable care organizations, care transitions

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