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June 6, 2019

Care Coordination Spotlight: Helping At-Risk Patients Stay at Home

For our latest use case spotlight, we sat down with Lorelei Morrissette, care coordinator at Support and Services at Home (SASH), to talk about how real-time information on care events has helped them provide better care for the patients they serve.

SASH, located in South Burlington, Vermont, partners with social-service agencies, community health providers, and nonprofit housing organizations across the state to provide assistance to over 5,000 seniors, adults with disabilities, and individuals with chronic conditions who live independently at home. SASH partners include Meals on Wheels, Area Agencies on Aging (AAAs), community health teams, Visiting Nurse Associations (VNAs), Vermont Centers for Independent Living, Bayada, healthcare and rehabilitation services, and more. Through close collaboration with these organizations, SASH ensures that its participants receive the services and care they need to maintain healthy, high-quality lifestyles in the comfort of their own homes.

SASH employs care coordinators and wellness nurses who perform regular at-home visits with participants. Care coordinators connect participants with the community programs and services they need to help meet their healthcare goals, while SASH wellness nurses monitor overall patient health and also provide educational services to members facing chronic conditions so they can better manage their health independently.

Can you give us a background on your role at SASH and some of the services that you provide?

As a care coordinator at SASH, I connect members with the resources they need to live successfully at home. Most of the members I work with are elderly, enrolled in Medicare or Medicaid, or have disabilities. I also work directly with one of the SASH housing partners, Brattleboro Housing Partnerships, which connects members in the Brattleboro area with housing. 

At SASH, we connect our participants with a wide range of services–really anything related to health and wellness. For example, if a patient is transitioning home after being discharged from a hospital or a nursing home, I coordinate logistics for them. I also work very closely with the SASH wellness nurse in my area to coordinate at-home visits to make sure things are running smoothly for our members. We also facilitate housekeeping services, or Meals on Wheels for members who may be faced with food insecurity. Additionally, I bring in programming to participants to educate them on the different health and wellness challenges they may be facing. We even provide exercise services such as Tai Chi!

Prior to PatientPing, what were some of the care coordination issues that you faced?

I started at SASH when we were in the beginning stages of implementing PatientPing, and it’s amazing the difference that it has made. Prior to PatientPing, we were only aware of SASH participants’ care events if providers remembered that the patient was enrolled in our program, or if the participant would speak up and inform them. If this didn’t happen, we often missed out completely on their care event, or provided duplicative services.

How are you using PatientPing today?

PatientPing has made a huge difference in how we’re able to provide care services today. We’re now notified in real time as soon as one of our participants has a care event. We’re able to quickly follow up on these events, and make sure that we’re taking immediate action.

How we use the PatientPing platform varies day-to-day. If I receive a Ping on a patient being discharged from the emergency department, I reach out to the care coordinator at the hospital to get the patient’s discharge plan so I can facilitate services, at-home visits, and also enroll the patient in the programs they need post-discharge.

For Pings received on patients in inpatient settings, I'll also reach out to the care coordinator at the hospital to determine the patient’s reason for admission, what their expected length of stay is, and to discuss a post-discharge plan. I then sync with my colleagues internally on steps that need to be taken for the patient post-discharge, who from SASH will be responsible for handling what, and whether or not the patient should receive care at home or in a SNF. By having this information ahead of time, we’re now able to get ahead of the game, and be proactive in facilitating services for our SASH participants.

PatientPing also has great features that help to make my job easier. For example, their text and email notifications are really helpful for care coordinators like myself who are often away from their computers and on the road visiting members. With these notifications, I know that I’m never missing a care event. I also use PatientPing’s visit histories to view patients' prior care events and if they are part of Medicare or Medicaid. Additionally, I can also see who patients' primary care providers are, as well as any additional care team members. I also use PatientPing's high utilizer flags to see which patients are frequently utilizing the ED.

Can you tell us about a time when PatientPing helped you to improve care for a patient?

I once received a Ping on a patient who was identified by PatientPing as a high utilizer. We looked into the patient’s visit history where we found that she had been presenting day after day to EDs in the area. I called the ED to learn more, and they explained that the patient had come in for multiple falls. When the ED discovered that nothing appeared to be broken, they would send her home. After speaking with the patient, we learned that she had no recollection of any of these falls. We discovered that the patient was suffering from severe memory loss, and was no longer able to live at home alone safely without medical support. We connected her to a program called Choices for Care, which has aides visit the patient’s home on a regular basis to assist her with her needs. Since we received this Ping, the patient has not returned to the emergency department, and is successfully receiving at-home services.

“I’m so thankful for PatientPing. It’s made a huge difference for us. When I first started at SASH almost 5 years ago, SASH was switching between different software and trying to find something just for the data tracking, we had no great resources at that point. PatientPing has been heaven sent.”  

Thanks so much for taking the time to speak with us and for your insights, Lorelei! 

Tagged: Care Coordination, healthcare, Healthcare Providers, SNFs, community providers, use case spotlight, at-risk populations

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