Patient Care Coordination Improves After Home Health Provider Connects to HIE

Date: December 19th, 2012Category: CORHIO e-NewsletterTopics: Care Coordination, Home Health

On their first day using CORHIO HIE data, Complete Home Health Care discovers vital data on an at-risk patient.

Complete Home Health Care (CHHC) is a Medicare/Medicaid certified home care agency serving clients along the Front Range with skilled nursing, rehabilitation, wound care, cardiac care, diabetic teaching, pediatrics, home health assistance and personal care.

Last month, CHHC had been having a difficult time tracking down a patient, after he was suddenly admitted to an area hospital. “We had been calling his home and had been in contact with the hospital after we learned he was admitted,” said Cathy Kaufman, CEO, Complete Home Health Care. “But when we called the hospital back to check his status, nobody seemed to know any information about him.”

An "A-Ha" Moment on Day One

The same week they had been tracking down this patient, the North locations of CHHC went live on CORHIO’s PatientCare 360®, a Web-based HIE tool that provides a longitudinal view of each patients’ medical history with information supplied by all of the hospitals, laboratories and public health entities connected to CORHIO. During their training session with CORHIO, the team decided to test the system by entering a specific patient’s name.

“Spur of the moment, we looked up this client we had been very concerned about,” said Kaufman. “Through the CORHIO system, we found out he had actually been transferred to another hospital to receive more specialized care.”

“The excitement over seeing that a patient had discharged, when they couldn't get an update from the hospital, was priceless,” said Janeece Lawrence, MPA, HIE Implementation Manager at CORHIO, who was the trainer for the CHHC team.

CHHC was able to contact the patient and resume home health care for him after his discharge. Since then, the patient has had positive outcomes and has been discharged from their care as well. He’s now doing great at home.

Typical Transition of Care Challenges

Complete Home Health Care can often spend a lot of time and effort tracking down patient information during a transition of care. “When we find out that a patient has gone to the hospital (which we don’t always find out right away), usually the hospital will call us to let us know the patient is now under their care,” said Kaufman. “But sometimes that doesn’t happen and we have to track down the patient – calling local area hospitals. My clinical supervisors are doing this, which is not what I need them to be doing. It takes us away from focusing on the patient care issues at hand.”

Receiving information on a patient via fax can also be challenging, said Kaufman. “Faxes are often unreadable. Pages can stick together and we have to make yet another phone call. Sometimes by that point, the record has gone to the medical records department and it could take days to get one missing piece of paper. Without having those results, we’re in the dark.”

Instant Access via HIE Will Improve Care

For current patients, Complete Home Health Care must be able to resume care within 24 hours of their discharge. So quickly finding accurate information on patient status, medications, labs and other results is of the utmost importance in continuing high-quality care.

“They could miss therapy, wound care or medications – the things we work really hard on as providers to avoid readmissions,” said Kaufman. “These gaps in care could put them right back in the hospital - they could take the wrong dosage or skip medications. These things are critical to their well-being and keeping them in the home setting and not in hospital.”

The “a-ha” moment during their HIE training has everyone at Complete Home Health Care thinking about the potential this tool has in improving their workflow. “I really see CORHIO helping us with our processes to streamline getting the information we need. I see us using it frequently, multiple times a day,” said Kaufman. “For us to be able to communicate better and partner with the doctors and facilities to exchange that information means we’re able to take better care of the patient.”