Patient Event Notifications Help InnovAge Manage Vulnerable Population

To stay apprised of their PACE members’ emergency department visits and hospital admissions and discharges, InnovAge turned to CORHIO’s Patient Event Notifications service.

InnovAge’s Colorado PACE (Program of All-inclusive Care for the Elderly) population of more than 2,700 members is managed by interdisciplinary teams of health professionals who coordinate their care needs. The program provides elderly participants with medical and dental services, and coordinated personal and skilled care in the home, as well as in the Day/Health Centers where socialization, meals and recreation are available.

Financing for the program is capitated, which allows providers to deliver any services the participants need rather than only those reimbursable under Medicare and Medicaid fee-for-service plans. Because InnovAge is managing all of the financial risk for these members, it’s important they understand when they are seen in a hospital and are able to quickly intervene to help avoid a readmission.

InnovAge turned to CORHIO’s Patient Event Notifications service for real-time alerts that let the care team at InnovAge know right away when one of their PACE members are having an ED or hospital encounter. Partial funding was made available to InnovAge for this project through the Colorado Care Connections Program.

“It’s crucial for us to know what’s going on with our patients, as we coordinate all their medical care, provide medications, and do in-home care as well,” says Jane Hill, Sr. Business Systems Analyst at InnovAge. “Sometimes it can be hard to find out if a patient went to the hospital, even after the fact. Some patients have dementia and they might not remember, or might not realize we want to know. And it’s understandable if their families aren’t thinking about calling to notify us of a hospital admission, as that is such a stressful time.”

Notifications Fit Easily Into Workflow

InnovAge sends an updated member file each month to CORHIO, and that list is matched up to any emergency department encounters or hospital admissions or discharges from our participating hospitals. Each notification is sent immediately to InnovAge in a format called HL7, (Health Level Seven), which is a standard for exchanging health information between medical applications. This format allows InnovAge to easily separate out data elements and route the notifications via secure email to the correct medical records staff. Those staff then coordinate with the interdisciplinary team of primary care providers, social workers, therapists and others.

“We see about 60 notifications* a day and because they come to us in a standardized format, it isn’t hard to break them up into individual data elements that can feed our workflow,” says Hill. “These messages give us an early heads up on the hospitalizations so we can more quickly follow up with the patient and see how we can help them.”

*Although InnovAge receives this volume of notifications, this does not indicate that 60 members a day are seen in a hospital. Multiple messages might pertain to the same member, as they are admitted, transferred, and discharged within a hospital system.

Information Can Lead to Changes in Care Plans

On a basic level, if InnovAge learns that a member is still at the hospital via a Patient Event Notification from CORHIO, they will reschedule any planned home health visits and transportation to external visits, and at discharge, follow up with the patient about what has recently happened. The information they learn from CORHIO can create significant changes in the member’s care plan. Upon notification of a hospital event, the care team can look in CORHIO’s PatientCare 360® portal for more information. For example, if they see that the member broke a hip, they can begin to plan how to best support the member’s return to their home, and plan for future recovery by scheduling a follow-up at the clinic and ongoing physical therapy. At a daily planning meeting, the interdisciplinary care team will discuss hospitalized members and look ahead to prepare after-care.

“One of the first things we do when we find out a member was in the hospital is to go into the CORHIO portal and find out what’s going on, and request full records from the hospital so we can start planning for their needs, ” says Hill. “We discuss how we can help them recover and get back into their homes and be safe. The CORHIO information helps us piece together the best plan to support our members.”

InnovAge is also storing all the data elements of each CORHIO Patient Event Notifications message they receive for future analysis. “We realized the wealth of data we are receiving, so we decided to hold on to it. Later, we can dive into it and look for trends,” says Hill. “We believe we could explore many avenues and find opportunities by looking at information about every single hospital visit our patients have.”