Latest / Becker’s Healthcare Podcast / Reimagining Care Coordination Across the Continuum with Data and AI

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Reimagining Care Coordination Across the Continuum with Data and AI · Becker’s Healthcare Podcast

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Hi, everyone. This is Lucas Voss with Becker's
0:02
Healthcare. Thanks so much for tuning in to
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the Becker's Healthcare podcast series. It's great to
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have you. I'm excited to welcome Robin Roberts
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and Novella Thompson to the podcast today. Very
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excited to have them. Robin is the director
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of health IT regulatory affairs at PointClickCare
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where she leads innovation and certified EHR technology,
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interoperability, and regulatory strategy for long term and
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post acute care. She's held leadership roles in
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health care policy, AI, and national interoperability
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efforts and is an active contributor to industry
0:30
groups, including
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the health care information and management system society,
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the PASEO project, and the EHR
0:37
Association.
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So excited to have her. Novella serves as
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administrator for the department of population health at
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UVA Health, providing strategic and operational leadership across
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programs that support patients throughout the continuum of
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care. With more than thirty years of health
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care experience, she's focused on advancing high quality
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patient centered care beyond hospital walls. She oversees
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a broad population health portfolio, including community paramedicine,
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remote patient monitoring, home health, mobile care delivery,
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digital literacy initiatives, and a value based care
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while partnering across UVA Health to drive care
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integration
1:14
strategy.
1:15
Novella and Robin, it's so great to have
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you both. Welcome to the podcast.
1:20
Thanks, Lucas. Glad to be here. Agreed. Thank
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you so much, Lucas.
1:24
I wanna hop right into the conversation because
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we certainly have a lot to discuss. There
1:28
is a lot to discuss, especially around value
1:31
based care. With value based care and reimbursement
1:34
changes increasing a lot of pressure on outcomes,
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Care coordination
1:38
looks very different than it did really just
1:42
a a few years ago.
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How are health systems
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taking
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a more proactive
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approach
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today? Novella, I'll start off with you here.
1:52
Great. Thank
1:53
you. Well, you're right. I mean, care coordination
1:56
has evolved as we've evolved from fee for
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service through,
2:00
and continuing,
2:01
throughout the different
2:03
models we are and have been experiencing in
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value based care.
2:08
The exciting part of that, though, is that
2:10
it has given us a lot of opportunities
2:12
to redesign care from the ED,
2:16
all the way through post acute and into
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our ambulatory
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spaces,
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inclusive, of course, within,
2:22
inpatient.
2:24
But
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today, we we're taking far more proactive approaches
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on the post acute end, which seems,
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you know, counterintuitive
2:33
to thinking. But
2:35
as soon as our patients discharge, they're assigned
2:38
a case manager, a population health case manager.
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And we're they're supported through a litany of
2:45
population health, or post acute care
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programming, which addresses needs around social drivers of
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health
2:53
and
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understanding
2:55
the barriers to health care while we're also
2:57
looking to improve the quality of care we
3:00
provide by
3:02
in ensuring that patient needs don't drop through
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the cracks of a very large academic medical
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center.
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It it's an exciting opportunity.
3:11
It it's a big lift. It's a change
3:13
of culture.
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But the reality is,
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taking care of patients outside of the hospital
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walls
3:21
positively
3:22
impacts the care that we're able to provide
3:25
inside
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our hospital and and ambulatory
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clinic walls.
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And as you've mentioned, treating this as an
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opportunity
3:33
is so crucial in approaching this. Robin,
3:36
are you seeing this similarly in terms of
3:38
the redesign? How are health systems taking a
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more proactive approach from your perspective?
3:44
Yeah. I think Novella said it best. Like,
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at places like UVA and other hospital and
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health system partners for us,
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we are seeing
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those systems
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want to use the SNF EHR data
3:56
as part of their infrastructure
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because it's not just about, you know, the
4:00
new cost containment and value based models to
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understand, you know, what's going outside of your,
4:05
you know, proverbial and very literal four walls
4:08
at the hospital and health system.
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It really is about those end to end
4:13
transitions. And so, you know, as soon as
4:15
Novella and the team member she's talking about
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have an inclination
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about a patient's discharge
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disposition,
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you know, they're able to proactively
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follow those populations
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now
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Using the longitudinal data in the record
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and so they're able to follow, you know
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in real times No one's waiting for a
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claim or that patient to bring back into
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the ed
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as soon as we are facilitating those handoffs
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and coordination, there is visibility now through and
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through
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into the skilled nursing facilities in those post
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acute stays. Whereas, you know, previously, I think
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it was kinda like a black box for
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a lot of health systems.
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You know, Vala, coming back to what you
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just mentioned and what Robin just said as
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well. Right? The the the opportunity and the
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change we're seeing, the more proactive approach
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certainly indicates that we have seen progress
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across the board, across the country.
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Where do you see still see coordination breaking
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down, though, particularly
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as patients transition into or out of that
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post acute care piece?
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You know, it'd be transitioning,
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from inpatient
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through,
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discharge planning
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and then discharge to,
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a post acute care facility
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is
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extremely
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complex
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often more often than not. And there are
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a lot of moving pieces. You have a
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lot of teams working together to move a
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patient through this process effectively and ensure
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that upon discharge, they have their medications. They're,
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discharged to the right place at the right
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time with the right care and the tools
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and resources they need post acute.
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And things can,
6:00
get lost in the mix and and lead
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to,
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issues
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for patients and for health care systems.
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We still find,
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areas where we're continuously
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working to improve
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that process to ensure,
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even down to the smallest detail that patient
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needs are are met.
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And one of those areas that I think
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continues to be a focus area is ensuring
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not only in our EMR,
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that the med reconciliation
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is correct and that the patient is leaving
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with the correct prescriptions,
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and that our
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post acute facilities
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have that information
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and it hasn't been transposed
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or changed inadvertently,
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is the greatest,
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opportunity
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for continuous improvement.
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It it it's too easy to transpose a
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number
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and or not send a medication list or
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send an old medication list
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and or the the
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in the in the case I'm thinking of
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a sniff partner
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receiving,
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a medication list that has an error.
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Robin, now given those challenges that Novella just
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outlined there in the beginning too,
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where do you see the greatest opportunities to
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improve care coordination
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at the hospital and the Nevesco skilled nursing
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facility intersection?
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Yeah. I think Novella called it out well,
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you know, that data is digital, but making
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that handoff to the SNF, sometimes it's not
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super actionable.
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She brings up a great example with making
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sure that we have the absolutely accurate med
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list. But even if we think about those
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summary of care and discharge summaries coming with
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the patient, a lot of times that documentation
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can be bloated for the staff, really. And
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so they're sitting there trying to take what
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they need,
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still conducting a bit of a manual curation,
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if you will, you know, into their workflows.
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And candidly, I think the other thing we
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see is, you know, from the hospital perspective,
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a single system
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works with numerous different SNFs. So then we
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have variability
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or, you know, there's a vast spectrum of
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heterogeneity
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in how those workflows process. And when you
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start to stack that up,
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there is still just some aspects of handoff
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that we are working to improve.
8:27
I wanna talk a little bit about the
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actual impact of this. Right? And we've touched
8:31
on it a little bit here in our
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conversation.
8:34
And, Novella, I I certainly touched on it
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in your in your introduction.
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You've done this for a very long time,
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and, again, your goal is to support patients
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throughout the continuum of care. I'd love to
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know if you have any patient stories or
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examples that you could share that sort of
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illustrate what we've talked about, what effective coordination
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looks like in practice
8:59
I look at this, the example I'm gonna
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share is really about system partnerships.
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And so
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UVA Health,
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medical University Medical Center
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partners and has for, you know, six years,
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multiple
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SNF,
9:16
facilities.
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And
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in that work
9:19
with discharging our patients, many
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are transported by our EMT partners
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or paramedic partners.
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And,
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I know this is gonna sound very archaic,
9:30
but,
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you know, a couple of years ago, as
9:34
recent as a couple of years ago, we
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had a partnership and a common thread of
9:38
communication that if a patient
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needed to be,
9:43
returned to the hospital for a a potential,
9:47
emergent issue or,
9:49
potentially a readmission,
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there was an orange folder,
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that was put with the patient in the
9:57
ambulance
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and then transported
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with the patient to the ED.
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Now I'd love for you to guess how
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many times that didn't show up.
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So that or, you know, regardless of how
10:10
hard we all try to do the right
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thing,
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that's just a,
10:16
an example of how easy it is. You
10:18
know, your intentions are good. The information is
10:20
solid.
10:21
But the way the process,
10:24
of hand to hand in an an emergent
10:27
situation,
10:28
can, break down very easily.
10:31
And so since since then,
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we now,
10:35
even the RED
10:36
originally pushed back. They they just because they're
10:39
so busy,
10:41
they came around, took the time, and and
10:43
understood
10:44
the the capabilities
10:46
of the pack management tool.
10:48
And,
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now
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our sniff partners put that information
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into
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their EMR.
10:55
That information,
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shows up very specifically,
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to,
11:02
our platform in our ED and our physicians
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and clinicians can provide
11:08
excellent care,
11:09
removing the middle man who I'm sure was
11:12
really glad to be removed,
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in the in the moment and how fast
11:16
paced EMT work has to be.
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But,
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you know, it's 2026.
11:21
You wouldn't think that maybe even in 2024
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we were doing that. But that that's the
11:25
case. And it's made a huge difference in
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the quality of care we're providing
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and the quality of communication
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between
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the medical center and our SNF partners.
11:37
Well, speaking of transporting
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a physical orange folder
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in a very busy environment,
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I wanted to talk I wanna talk a
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little bit about technology, which has certainly made
11:49
a difference and hopefully,
11:51
across most places in The US eliminated,
11:54
an orange folder, potentially. Great.
11:57
I I wanna talk a little bit about
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AI. I think we can't leave this conversation
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without not having talked about AI here. And
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and, Robin, I wanna start with you here.
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What role is AI playing in supporting care
12:09
coordination
12:10
today, and where do you see
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the greatest near term opportunities for AI to
12:15
really improve the clinical and operational workflows that
12:19
we've outlined today?
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Yeah. Well, at PointClickCare, I think one of
12:23
the neatest uses of artificial intelligence that we
12:26
have, that there's some shared visibility with the
12:28
the within the sniff in the hospital
12:30
is predictive return to hospital
12:32
where we're essentially looking at readmission and deterioration
12:35
risk that is based on real world sniff
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data.
12:39
And so looking at, you know, post acute
12:42
encounters and predicting numerically,
12:45
you know, the likelihood
12:46
of readmission or ED risk and surfacing those
12:50
scores,
12:51
in the SNF EHR into those hospital and
12:54
health system dashboards.
12:56
The other thing, of course, we're doing across
12:58
the network
12:59
is the monitoring, the real time alerts of
13:02
those admission discharge and transfer.
13:05
And so, you know, I definitely wanna hear
13:06
what Novella's thinking, but I I just wanna
13:08
tie that back. You know, as we're talking
13:10
about artificial intelligence and machine learning and the
13:12
the potential it has, I think the other
13:15
thing we have to think about is the
13:17
people process and tech and the long term
13:19
partnerships and their convergence with this technology.
13:22
I think that's really where the rubber is
13:24
gonna meet the road.
13:26
Yeah. It becomes an enabler for the proactive
13:29
opportunity that we've touched on in our conversation,
13:31
I feel like. Again, that's the role technology
13:33
plays most of the time as an enabler.
13:34
Novella,
13:35
how are you seeing this? What role is
13:37
AI playing in support in care coordination today?
13:40
What have you seen
13:42
the the or the greatest near term opportunity
13:44
for you when you think about AI?
13:47
Well, I think it's I think it's exciting
13:49
for for for sure, and I think there
13:51
are a lot of ways that it can
13:53
be utilized, you know, with with parameters,
13:56
in health care. One of the most exciting
13:58
things I'm seeing and looking forward to is
14:01
not only
14:02
the ability
14:05
to see patients and provide clinical documentation without
14:08
the excess amount of time, we call it
14:10
p j time,
14:12
that our physicians and clinicians put into place
14:15
mainly during off hours. But
14:17
one of the hardest things to
14:20
predict in a patient's, you know, inpatient's
14:24
stay,
14:25
is the discharge date.
14:27
And try as, hard as our physicians and
14:31
clinician teams manage
14:33
throughout the process,
14:34
predicting that discharge date based on a litany
14:37
of
14:38
issues,
14:39
mainly as, you know, social driver of health
14:41
issues, whether it's caregiver support, Medicare spend downs,
14:45
needing a UAI,
14:47
whatever the case might be.
14:49
I'm looking forward to,
14:52
AI that helps us better predict that discharge
14:55
date the day the patient is is admitted
14:58
because that's really when discharge begins.
15:01
And so from that,
15:03
then we begin working on the barriers versus
15:07
later down the line
15:08
figuring out the the barriers to to discharge
15:12
and trying to determine how to remove those
15:15
barriers
15:16
while still guessing,
15:18
and managing through our our current processes
15:21
that discharge state.
15:23
It it's it's exciting to think about partnering
15:25
in that space and also
15:28
continuously,
15:30
improving our communication
15:32
amongst our partners internally and externally.
15:36
Certainly more exciting than a physical folder or
15:38
sending a fax.
15:40
Agreed.
15:43
Well, it's so great to have you both.
15:44
I wanna turn the floor over to you
15:46
here as we close out our episode. Anything
15:49
else you'd like to share with our audience
15:50
that we haven't covered or that's important to
15:52
understand here? Robin, I'll I'll start off with
15:54
you.
15:55
No. I just think that the future of
15:57
care coordination is really about connecting the dots
15:59
we've already drawn,
16:01
using
16:02
the data and tools we have to make
16:05
those handoffs
16:06
deliberate to ensure that they're visible and that
16:09
there's really accountability
16:11
across the episode
16:12
Not just within our four walls, and I
16:15
think that the future belongs to those that
16:16
are doing that No, vala over to you.
16:19
I I think one of the most important
16:21
pieces is for medical centers and academic medical
16:24
centers to realize that post acute care
16:27
and partnering
16:28
with
16:29
institutions and facilities,
16:31
you know, for patients
16:33
to address the needs
16:35
in that space
16:36
is more important today than it ever was
16:39
and must be a part of the continuum
16:41
of care.
16:42
Oftentimes, patients are discharged,
16:44
and and that's that. We have found through
16:47
a decade of service in this space
16:50
that we're able to improve
16:53
outcomes. We're able to improve
16:56
the quality of care.
16:57
We're able to improve the continuity of care
17:00
for our patients while we also do the
17:03
same for our inpatient,
17:05
our ED, ambulatory,
17:06
and post acute care teams. It's win win,
17:09
and it's a great like I said earlier,
17:12
it's a great opportunity.
17:14
Well, Navella and Robin, again, thank you so
17:16
much both for being here, sharing your insights.
17:18
I also want to thank our podcast sponsor,
17:20
PointClickCare, for bringing us together for this great
17:23
conversation,
17:24
and you could tune in to more podcasts
17:25
from Becker's Healthcare by visiting our podcast page
17:28
at beckershospitalreview.com.