Reimagining Care Coordination Across the Continuum with Data and AI

0:00Hi, everyone. This is Lucas Vahas with Becker's Healthcare. Thanks so much for tuning in to the Becker's Healthcare podcast series. It's great to have you. I'm excited to welcome Robin Roberts and Novella Thompson to the podcast today. Very excited to have them. Robin is the Director of Health IT regulatory affairs at point. Click, Care, where she leads innovation and certified EHR technology into operability and regulatory strategy for a long term and post-acute care. She studied leadership roles in healthcare policy, AI and national interoperability efforts and is an active contributor to industry groups, including the healthcare information and management system society, the passive project and the EHR association. So excited to have her. Novella serves as administrator for the Department of Population Health at UVA Health, providing strategic and operational leadership across programs that support patients throughout the continuum of care with more than 30 years of healthcare experience. She's focused on advancing high-quality patient centered care beyond hospital walls. She oversees a broad population health portfolio, including

1:00community paramedicine, remote patient monitoring, home health, mobile care delivery, digital literacy initiatives and a value-based care while partnering across UVA Health to drive care integration strategy. Novella and Robin, it's so great to have you both. Welcome to the podcast. Thanks, Lucas. Glad to be here. I agree. Thank you so much, Lucas. I want to hop right into the conversation because we certainly have a lot to discuss. There is a lot to discuss, especially around value-based care with value-based care and reimbursement changes increasing a lot of pressure on outcomes. Care coordination looks very different than it did really just a few years ago. How are health systems taking a more proactive approach today? Novella, I'll start off with you here. Thank you. Well, you're right. I mean, care coordination has evolved as we've evolved from fee-for-service through and continuing throughout the different models we

2:04are and have been experiencing in value-based care. The exciting part of that, though, is that it has given us a lot of opportunities to redesign care from the ED all the way through post-acute and ambulatory spaces, inclusive, of course, within inpatient. But today, we're taking far more proactive approaches on the post-acute end, which seems counterintuitive to thinking. But as soon as our patients discharge, they're assigned a case manager, a population health case manager, and they're supported through a litany of population health or post-acute care programming, which addresses needs around social drivers of health and understanding the barriers to health care while we're also looking to improve the quality of care we provide by ensuring that patient needs don't drop through the cracks of a very large academic medical center.

3:09It's an exciting opportunity. It's a big lift. It's a change of culture, but the reality is taking care of patients outside of the hospital walls, positively impacts the care that we're able to provide inside our hospital and ambulatory clinic walls. And as you've mentioned, treating this as an opportunity is so crucial in approaching this. Robin, are you seeing this similarly in terms of the redesign? How are health systems taking a more proactive approach from your perspective? Yeah, I think Novelis at best, like it places like UVA and other hospital and health system partners for us. We are seeing those systems want to use the SNF EHR data is part of their infrastructure because it's not just about the new cost containment and value-based models to understand what's going outside of your proverbial and very literal four walls. At the hospital and health system, it really is about those end-to-end transitions.

4:14And so as soon as Novela and the team member she's talking about having inclination, about a patient's discharge disposition, they're able to proactively follow those populations now using the longitudinal data and the record. And so they're able to follow in real times. No one's waiting for a claim or that patient to boring back into the ED. As soon as we are facilitating those handoffs and coordination, there is visibility now through and through into the skilled nursing facilities in those post-acute stays, whereas previously I think it was kind of like a black box for a lot of health systems. Novela, coming back to what you just mentioned and what Robin just said as well, right? The opportunity and the change we're seeing, the more proactive approach certainly indicates that we have seen progress across the board, across the country. Where do you still see coordination breaking down though, particularly as patients transitioned into or out of that

5:16post-acute care piece? You know, the transitioning from inpatient through discharge planning and then discharge to a post-acute care facility is extremely complex, often more often than not. And there are a lot of moving pieces. You have a lot of teams working together to move a patient through this process effectively and ensure that upon discharge they have their medications, their discharge to the right place at the right time, with the right care and the tools and resources they need post-acute. And things can get lost in the mix and lead to issues for patients and for health care systems. We still find areas where we're continuously working to improve that process to ensure even down to the smallest detail that patient needs

6:21are met. And one of those areas that I think continues to be a focus area is ensuring not only in our EMR that the med reconciliation is correct and that the patient is leaving with the correct prescriptions and that our post-acute facilities have that information and it hasn't been transposed or changed inadvertently is the greatest opportunity for continuous improvement. It's too easy to transpose a number and or not send a medication list or send an old medication list and or the case I'm thinking of a SNF partner receiving a medication list that has an error Robin now given those challenges that novella just outlined there in the beginning to

7:23where do you see the greatest opportunities to improve care coordination at the hospital and the SNF the skilled nursing facility intersection. Yeah I think novella called it out well you know that data is digital but making that hand off to the SNF sometimes it's not super actionable. She brings up a great example with making sure that we have the absolutely accurate med list but even if we think about those summary of care and discharge summaries coming with the patient a lot of times that documentation can be bloated for the staff really and so they're sitting there trying to take what they need I'm still conducting a bit of a manual curation if you will you know into their workflows and candidly I think the other thing we see is you know from the hospital perspective a single system works with numerous different SNFs so then we have variability or you know there's a vast spectrum of heterogeneity and how those workflows process and when you start to stack that up there is still just some aspects of handoff

8:25that we are working to improve. I want to talk a little bit about the actual impact of this right and we've touched on it a little bit here in our conversation and novella I certainly touched on it in your in your introduction you've done this for a very long time and again your goal is to support patients throughout the continuum of care I'd love to know if you have any patient stories or examples that you could share that sort of illustrate what we've talked about what effective coordination looks like in practice today. Oh absolutely thanks that's a great point and opportunity to share I look at this I'm the example I'm going to share is really about system partnerships and so UVA Health Medical University Medical Center partners and has for you know six years multiple SNF facilities and in that work with discharging our patients many are transported by our EMT partners or paramedic partners and I know this is going to sound very archaic but

9:30you know a couple of years ago as recent as a couple of years ago we had a partnership and a common thread of communication that if a patient needed to be returned to the hospital for a potential emergent issue or potentially a readmission there was an orange folder that was put with the patient in the ambulance and then transported with the patient to the ED now I'd love for you to guess how many times that didn't show up so that you know regardless of how hard we all try to do the right thing that's just an example of how easy it is you know your intentions are good the information is solid but the way the process of hand to hand in an emergent situation can break down very easily and so since since then we now even the RED and originally pushed back they they just

10:39because they're so busy they came around took the time and understood the capabilities of the PAC management tool and now our SNF partners put that information into their EMR that information shows up very specifically to our platform in our ED in our physicians and clinicians can provide excellent care removing the middle man who I'm sure was really glad to be removed in the moment and how fast pace EMT work has to be but you know it's 2026 you wouldn't think that maybe even in 2024 we were doing that but that that's the case and it's made a huge difference in the quality of care we're providing and the quality of communication between the medical center and our SNF partners well speaking of transporting a physical orange folder in a very busy environment

11:44I wanted to talk I want to talk a little bit about technology which has certainly made a difference and hopefully across most places in the US eliminated an orange folder potentially I want to talk a little bit about AI I think we can't leave this conversation without not having talked about AI here and and Robin I want to start with you here what role is AI playing in supporting care coordination today and where do you see the greatest near term opportunities for AI to really improve the clinical and operational workflows that we've outlined today yeah well at point click here I think one of the neatest uses of artificial intelligence that we have that there's some shared visibility within the SNF in the hospital is predictive return to hospital where we're essentially looking at readmission and deterioration risk that is based on real-world SNF data and so looking at you know post-acute encounters and predicting numerically

12:44you know the likelihood of readmission or ed risk and surfacing those scores in the SNF EHR and to those hospital and health system dashboards the other thing of course we're doing across the network is the monitoring the real-time alerts of those admission discharge and transfer and so you know I definitely want to hear what novellas thinking but I just want to tie that back you know is we're talking about artificial intelligence and machine learning and the the potential it has I think the other thing we have to think about is the people process and tech and the long-term partnerships and their convergence with this technology I think that's really where the rubber is going to meet the road yeah it becomes an enabler for the proactive opportunity that we've touched on in our conversation I feel like again that's the role technology place most of the time as an enabler novella how are you seeing this what role is AI playing in support in care coordination today what have you seen the the or the greatest near-term opportunity for you when you think about AI

13:47well I think it's I think it's exciting for for for sure and I think there are a lot of ways that it can be utilized you know with with parameters in health care one of the most exciting things I'm seeing and looking forward to is not only the ability to see patients and provide clinical documentation without the excess amount of time we call it PJ time that our physicians and clinicians put into place mainly during off hours but one of the hardest things to predict and a patient's you know in patients day is the discharge date and try as hard as our physicians and clinician teams manage throughout the process predicting that discharge date based on a litany of issues mainly as you know social driver of health issues whether it's caregiver support Medicare spend downs needing a UI whatever the case might be I'm looking forward to AI that helps us

14:53better predict that discharge date the day the patient is admitted because that's really when discharge begins and so from that then we begin working on the barriers versus later down the line figuring out the the barriers to to discharge and trying to determine how to remove those barriers while still guessing and managing through our current processes that discharge state it's exciting to think about partnering in that space and also continuously improving our communication amongst our partners internally and externally certainly more exciting than a physical folder or sending effects it's so great to have you both I want to turn the floor over to you here as we close out our episode anything else we'd like to share with our audience that we haven't covered or that's important to understand here Robin I'll start off with you and no I just think that the future of

15:57care coordination is really about connecting the dots we've already drawn using the data in tools we have to make those handoffs deliberate to ensure that they're visible and that there's really accountability across the episode not just within our four walls and I think the future belongs to those that are doing that no value over to you I think one of the most important pieces is for medical centers and academic medical centers to realize that post-acute care and partnering with institutions and facilities you know for patients to address the needs in that space is more important today than it ever was and must be a part of the continuum of care oftentimes patients are discharged and and that's that we have found through a decade of service in this space that we're able to improve outcomes we're able to improve the quality of care we're able to improve the

16:59continuity of care for our patients while we also do the same for our inpatient our ED ambulatory and post-acute care teams it's win-win and it's a great like I said earlier it's a great opportunity well and Robin again thank you so much both for being here sharing your insights I also want to thank our podcast sponsor point click care for bringing us together for this great conversation and you can tune into more podcasts from becker's health care visiting our podcast page at becker's hospital review dot com