Netsmart CareThreads
Netsmart CareThreads

Episode · 2 months ago

Closed Loop Referrals w/ Electronic Transition of Care


Manual referrals, besides being inefficient, do not provide effective care. When we move to electronic transitions of care, we have a tremendous advance in referral management that provides the best outcomes for patients.


In this episode of Netsmart CareThreads, Dr. Holly Miller, Chief Medical Officer at MedAllies, shares the benefits of and case studies for electronic transition of care.  

Join us as we discuss:

-Why manual referrals underserved patients

-How incentive programs provided benefits for patients and providers

-Who the 360X workgroup was designed to help

-Use cases for electronic transitions of care

-First steps for implementing closed-loop referrals 

To hear more episodes like this one, subscribe to Netsmart Care Threads on Apple Podcasts, Spotify, or your favorite podcast player.

Welcome to Netsmart Care Threads, apodcast where human services and post acute leaders across the healthcare continuum come together todiscuss industry trends, challenges and opportunities. Listen as we uncover real stories abouthow to innovate and improve the quality of care for the communities we serve.Let's get into the show. Welcome everyone to today's podcasts. My name isAJ Peterson, vice president and general manager of Care Guidance Solutions at Netsmart.Today's podcast topic is connected community, closing the gap. I'm very pleased tobe joined today by Dr Holliy Miller, chief medical officer with met allies.She's been championing efforts across the industry to improve closed loop referral technology as wellas drive greater provider adoption. So first just set some context around the podcast. You know, it's our belief that interoperability and the seamless sharing of informationso really always be at the forefront of the design of technology solutions and servicesfor providers. Being able to further connect to all healthcare is vital to ensuringthat the best health outcomes for individuals and for healthcare organizations are really thrive andany value base care landscape that they may be navigating in the healthcare it industryhas been really taking steps to improve clinical care delivery by implementing new interoperability standardsthat support the automation specifically at closed loop referrals, helping the streamline the waysprimary care providers, for example, are informed on how they track their consumersand patients as they see specialists outside of their care setting. So really providersbenefit from being informed on a person's referral status as they refer and transfer caresettings and they can actually measure not only the progress but also, in shorttimely access to care. At the same time, they're also responsible for trackingclinical outcomes as part of participation in these...

...integrated care models. So the newstandards were really focus on areas to improve overall referral management, closing the communicationgaps and really enabling transparency between care settings. So I want to bring in DrMiller into the conversation. So welcome Dr Miller to the PODCAST and Iwanted to start, if you wouldn't mind explaining a little bit as a clinician, why this work around closed superferrals is so important and what's the value thatyou see to clinicians improviders alike. First Age, thank you for that kindintroduction and to tell you that it's a pleasure just be put you. Butthis is a topic that is probably the nearest and dearest to my part,because I can think back to the days when we would make a referral fora patient to see a specialist. Six months later that patient might be backin my office or a year later, never having arranged an appointment gone tosee the specialist, and I wouldn't have known. My staff probably were tryingto do their best to follow up, keeping spreadsheets of who've been referred,but it was a manual process and very difficult to the track if the patienthad seen a specialist. Most often I didn't have the information from the specialist, so I'd be sitting there with the patient asking the patient, well,what did he or she say and what were the recommendations? What medications didthey put you on? And the patient may or may not remember what thatprocess was. So it really was very inefficient and not effective care. Sowith the incenter programs, we then were asked to perform electronic transitions of care. This was a tremendous advance. So instead of receiving paper or not gettinginformation. I could both send information about my patient to a specialist I wasasking to see my patient and also received back information from that specialist. Alot of the most important data, like...

...diagnoses and medications, was being sentthem as discreete data, so they could actually pull that data right into theirown electronic health record and use it immediately. This eliminated transcription arrows and it's savetime for the specialist and his or her staff. In addition, whenthey were completed with their work, they could send me the consult and againI could pull that information into my record and I could keep up to datewith what was happening with my patient. But this didn't solve the problem oftracking these referrals. Three hundred and sixty x goes beyond electronic transition of careto really track the referrals. And actually that's where the expression three hundred andsixty comes from, because it's a circle the the the first line starts thearc of the circle to the specialist and then the second line closes that loopwith my getting the information back. And at all points of the process mystaff will know did the patient get an appointment? Did the patient gets seeingdid the patient no show? So information is flowing to track the progress ofthe referral. So it's really a huge advance. That's fantastic. Of lookingat it both from the perspective of how can I receive greater visibility to mypatient or consumer as they're being referred into a specialty provider, but then alsoyou touch down the clinical integration component of how do I take data and makeit meaningful and actionable inside of my health record to really driving not only aworkflow but a knowledge flow on the person. So that that that is great context. So you know, if you don't mind, can you talk alittle bit about more about the three hundred and sixty x initiative, kind ofhow is it organized, to give a little history around it, and thenalso who's participating? WHO's participating in this three hundred and sixty ex work group? So from the inception three hundred and...

...sixty x and sponsored by the Officeof the National Commissioner for Health Information Technology, fondly known as ONC, they sponsoredthis. They are looking to improve care transitions, specifically in the waysthat we've already talked about. Since the inception of the of the group,three hundred and sixty x has input from a broad representation of various roles throughoutthe public and private sectors. These include commissions, technical experts and representation frommany trying to health record and health information technology vendors and obviously also with OWNCrepresentatives. Excellent and having such a wide kind of breath of a different organizations, both at the federal level but then also at the individual hit level,really helping to get supporting legs around its initiative. So can you talk alittle bit around you know, how was the industry planning to use this technologyor what are some of the high value use cases that you see this standardin this use use case group being able to publish out to the broader community? Well, initially three hundred and sixty x was designed exactly as we've beentalking about, for specialty referrals, and since then we've looked at some otherhigh value use cases and those have included, very importantly, acute or ambulatory transferto skilled nursing facility. This is something that happens much more frequently thanpeople anticipate. There's a huge population of patients treated in long term postsecute care, so having to be sixty x in long term possecute care. We thoughtwas was critically important. Most recently, the group took into consideration the usecases that were so relevant to the pandemic, to Covid nineteen pandemic, and thoseincluded taking into consideration thinking about all...

...the patients that the morbidity that wasgoing on in still nursing facilities and what we could do to help that thosepatients in that process. So we looked at using three hundred and sixty xfor skilled nursing facility to emergence, you department transfers. The other pandemic inspireduse case that the group has taken on is really acute and ambulatory referrals tosocial determinant of health needs community based organizations. We feel that with all of thechanges in life situations for people affected by the pandemic, job changes,job losses, that this was something that would be critically important to address.I can tell you as a clinician, if I'm not thinking about my patientssocial determinant of health needs, I'm really not treating the whole person and oneof the let me give you an example. If I have a diabetic pation andI'm doing excellent clinical care, recommending that they eat a diabetic compliant dietand that they check their fingers to bluecost regularly and that they take their medication. Well, if their homeless, some of those things are probably impossible.So it's really important that I'm able to take the entire patients situation into considerationand be able to make these critical referrals so that they can then address theneeds in their lives as well as follow through with the clinical care that's required. Yeah, I think that. I think it hits the nail on thehead there. You know, when we look at connecting the mind and thebody together, it is so important that we're looking at both physical as wellas behavioral and, in this instant, social aspects of care, because ifan individual who is suffering from a behavioral health condition, in a physical healthcondition, can't find stable housing or food...

...for their family, they're less likelyto be able to follow through on the care plans or the medication regiments thatthe providers are are prescribing for them. So taking into account the social aspectsof an individual's health is important and this is often a undigitized part of healthcare. So I applaud the efforts of the of the group to expand out theuse of such an important tool as closely preferrals, to really start to incorporatethe social service organizations that are so critical to the care of the individuals thatwere serving. And that's exactly right. All right. So when we thinkabout you know, who's participating and how are healthcare I vendors coming together reallydrive this from a work group standard into an actual production use, can youshare a little bit around where we are as a as a broader community inputting in a very critical tool like three safe t x into production use?Great question and, as I mentioned, there are so many persons in thethe weekly three hundred and sixty x calls that really go across any hr hitvendors. But I have I'm very happy to say that the following HR vendorshave said that they plan to release three hundred and sixty x either in twothousand and twenty one or two thousand and twenty two. And top of thelist, I think net smart already has released three hundred sixty x, butepic plans to release three hundred and sixty X. ECW has said they planto Matrix care and no to all plan to have three hundred and sixty xand production. Can I ask you, Aj what has led net smart toparticipate in the three hundred and sixty x project? Yeah, thank you,Dr Miller. And you know, we're proud to participate in this project becausewe see it is so critical as we think about how we digitize the communitybased providers in one of the key strategies... success from quality care patient caredelivery is how well we connect into the rest of healthcare and being able tolink our human service clients and our senior living in care at home clients totheir referral partners on the health system side. You in ambulatory physical health is sovery important. As we know, one of the most fragile times ofan individual care journey is when they transition from one care setting to the next. So we net smart look at this as a great opportunity from a technologyperspective to help close that gap and create a more seamless transition of care thataccounts for all of the individuals needs and creating a provider efficiency when a personis transitioning from one care setting to the next. So we look at thisas a great opportunity for us to help the industry take a step forward aswe care for individuals that move from their journey from a queue to ambulatory intothe community based care provider setting. So maybe to kind of take us infor a landing. Dr Miller, for our audience here are podcast audience.What recommendation would you make to them in order to get started into thinking aboutelectronic referrals, closed loop referls and transitions of care? Well, I thinkthe first step for anyone is to ask their electronic health record vendor is thisavailable and, if not, when will it be available, and if theydon't have it on their road map, insist that it become available. What? And let me turn the question to you. How will do your netsmart customers at this point perceed? We've talked about all the organizations that aregoing to be where, all the vendors that will be live with that withhundred and sixty x. How will the Netsmart customers plan this? Yeah,great question. So we've made the three hundred and sixty x protocol available insideof our care records for specific communities,... clients that are interested in learningmore about three hundred and sixty x can reach out to their nest smart clientrepresentative and can talk about mapping a path forward to bring our clients live onthe standard. But then also help us is Dr Miller mentioned that other hikevendors, like epic and others, are looking for opportunities to link up communitybased providers. So let's start the collaboration of looking at opportunities where we canimplement and leverage the three hundred and sixty x standard in order to bridge thatgap between acute, ambulatory and community based providers. So really excited to getthe community engaged and to raise their hand to want to participate. So withthat I'm going to take AU sin for landing. So, Dr Melon,thank you so much for joining me today and the PODCASTS, and we lookforward to continue the great work the communities doing around closer referrals as we reimagineconnected care in order to support the whole person. Being able to further connectall the healthcare is vital to ensuring the best health outcomes for consumers and pageseems the like, as well as the supporting provider organizations, to thrive anew value based care. So thank you again for your time on the podcastand thank you again for your leadership in the community. The bridge are ourprovider communities together. Through the great work around closed loop referrals that net smart, we understand the challenges facing provider organizations. Our team will help you navigate changingvalue based care models with solutions and services that make person centered care areality. Will equip you with technology and services that provide holistic, real timeviews of care histories that inform better decisionmaking and better outcomes. visit us todayat intstcom. Net smart serving you so you can serve others. Thanks forlistening to the net smart care threads podcast. Through collaboration and conversation, we canwork together to make healthcare more connected...

...than ever before and better support thecommunities we serve. To ensure you never miss an episode, please subscribe tothe show in your favorite podcast player, if you use apple podcasts. We'dlove for you to give us a quick rating for the show. Just havethe number of stars that you think the podcast deserves. Until next time,.

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