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Case Studies
Case Management Awareness
Division of Long Term Services and Supports (LTSS) provides home and community-based services for South Dakotans who meet program eligibility to help them remain living in the community who without these services, would require nursing facility care.
Use Case: Provide Event Notifications and Point of Care access to LTSS Specialists in order to actively participate in discharge planning and improve care coordination for program eligible consumers.
Project Details
•SDHL provides real-time clinical event notifications
•Access to Point of Care clinical documentation
•Outcomes for successful diversions to LTC
Impact
•LTSS real-time notifications allow specialist to actively participate in the discharge process to determine consumer needs and avoid potential admissions to nursing facilities
•Improved care coordination for consumers and improves their ability to return home
•Patient satisfaction.
Notifications for Managing Bundled Payments
CMS and Medicaid are paying providers for episodes of care versus individual services.
Use Case: The facility wants to manage their overall bundled payment patients after initial discharge, by monitoring their ED and inpatient admissions.
Project Details
•Leverage existing ADT feed to SDHL
•Subscribe to event based notifications
•Identify patients pending re-admission for care management, admission prevention
•Upload post surgical patient list
Impact
•New improved workflow promotes better care
•Better outcomes
•Maximized reimbursement
FQHC Practice: Improving Transitions of Care
One of the largest risks for readmission after hospital discharge is lack of timely follow-up with their PCP. A challenge is to know when a patient has been discharged in order to provide ongoing support during this critical time.
Use Case: Use Event Notifications so providers and care teams can create the best outreach and treatment plan.
Project Details
•Leverage existing ADT feed to SDHL
•Subscribe to event based notifications
•Upload specialized patient list
•Use Point of Care to access post-discharge instructions, and to schedule follow-up appointment to support continuity of care.
Impact
•Enhances ability to spend less time on administrative work and more time on supporting and coaching the patient as event occurs.
•Patient: improves safety and reduces exposer for adverse drug or medical events
•Allows for opportunities to increase reimbursement rates for chronic care management
Support Patient Routing to Appropriate Care Setting
A large number of ED visits are for non-urgent conditions. This can lead to increased healthcare costs, unnecessary testing, and weakened provider-patient relationships.
Use Case: Use Event Notifications allowing providers the opportunity to outreach to patient in order to review patient status and to determine appropriate level of care.
Project Details
•Leverage existing ADT feed to SDHL
•Subscribe to event based notifications
•Upload specialized patient list – frequent utilizers
Impact
•Lower healthcare costs and maximize reimbursements
•Support patient by providing individualized care plans, intensive care management, and review of any barriers to care.
•Decrease exposure and risk for adverse events
Dental Services: Improving Care Coordination
Oral health and dental teams play a critical role in patient’s overall care model. As a result, the need for improving communication and awareness for dental teams is essential for improving overall care coordination efforts.
Use Case: Use Event Notifications to notify dentists when a patient has received care in the community for dental related complaints or procedures.
Project Details
•Leverage existing ADT feed to SDHL
•Subscribe to event based notifications
•Upload specialized patient list
Impact
•Improved transfer of information and coordination of care between specialists
•Enhances ability to make any changes to treatment plan to provide ongoing support.
•Supports ongoing clinical management and scheduling of follow-up visit post-discharge
FQHC Following Patients Seen in the Last Six Months
Horizon Health Care provides patients across South Dakota with primary, medical, and dental care. They not only work with one hospital, but multiple hospitals across the state, where their patients can present at.
Use Case: Use Event Notifications to receive timely notifications on patients admitted and discharged from the ED or inpatient status. Access Point of Care to print and download the discharge summary and view other clinical information.
Project Details
•Provide inpatient and ED admit/discharge notifications to end-users.
•Access to pertinent clinical information via Point of Care Exchange
Impact
•More efficient and timely follow up
•Faster Access to discharge summaries
•Patient and care team satisfaction