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How one hospital successfully overhauled care management

Care coordination is at the epicenter of the healthcare industry’s shift to value-based care. Hospitals will succeed only if they evolve this function to meet the demands of new risk-based financial models. 

Holyoke Medical Center (Holyoke, Massachusetts, U.S.A.) successfully redesigned its care management function. The more unified approach earned improvements in several Press Ganey ratings related to care coordination within just six months.

“One of the challenges we had was that our outpatient and inpatient case management efforts were disconnected. Departments couldn’t see what the others were doing, so we risk loss of continuity of care,” said Director of Transitional Care Management Michael Ipekdjian RN, BSN, PHRN. “To accomplish quality care across the continuum, you can’t have these siloes.”

Unfortunately, disconnected systems contribute to gaps in communication, which can lead to gaps in care. Beyond potential risk for the patient, it can cause organizations to lose out on shared savings and bundled payments, too. Holyoke Medical Center participates in Centers for Medicare & Medicaid (CMS) value-based programs, including Medicare Shared Savings Program (MSSP) and Model 2 Bundled Payments for Care Improvement (BPCI) Program.

Holyoke Medical Center set out to redesign its care management program. Goals included providing superior transitional care management services, improving clinical outcomes, sustaining reduced readmission rates and improving utilization of appropriate services.

The new structure includes an inpatient Case Management department, outpatient Community Navigation department and a Patient Call Center to engage patients post-discharge. All teams report into the same leadership, but they needed a more unified technology solution to more effectively coordinate care.

Holyoke Medical Center selected Allscripts CareInMotion™ to deliver a single platform to encompass discharge planning, utilization management and evidence-based care plans. A three-phased implementation helped enable more seamless transitions for patients and closed gaps for better patient care.

“We operationalized a significant amount of technology in six months, and now we’re looking at ways to use national risk stratification and predictive analytics,” Ipekdjian said. “We’re closing the gaps in care transitions…it’s an exciting time for us.”

To learn more about how Holyoke Medical Center used Allscripts CareInMotion to improve care management, download a case study.

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