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Care Navigation Meets Tech with this Tool

Analysis  |  By Alexandra Wilson Pecci  
   August 15, 2017

A tool developed by Northwell Health helps to identify patients who might benefit from being enrolled in a transitional care program upon discharge.

Nine Northwell Health Solutions hospitals were named among the "most wired" in the country last month, a designation that recognizes a hospital's success in using technology to engage with patients.

Among the initiatives at the New York-based network is the Care Tool, a homegrown health IT tool that has helped to reduce readmissions by connecting care navigators, patients, and health information in real time.

The Care Tool has been years in the making, and has constantly evolved since it was first deployed three years ago, says Jennifer Laffey, DNP, FNP-BC, supervisor for transitional care programs.

She and her colleagues use the Care Tool to help identify patients who might benefit from being enrolled in a transitional care program when they're discharged.

The tool pulls information and data about the patient from any electronic source, casting a wide net to identify hospitalized patients who may qualify for a transitional care program.

Clinicians decide whether to enroll the patient (although patients ultimately decide if they want to participate in care navigation, Zenobia Brown MD, MPH, Medical Director, AIM, Northwell Health Solutions, notes via email).

Once a patient is identified and enrolled in the program, a care navigator will meet with them while they're still in the hospital.

"It builds that trust relationship from the first minute," Laffey says.

Discharge will trigger the start of the care coordination program, which lasts either 30 or 90 days, depending on the diagnosis. For instance, the comprehensive joint replacement model is 90 days long.

The navigator also serves as the primary point of contact for the patient and their caregivers throughout the duration of the program once they're enrolled, with the help of the tool.

The Care Tool will provide real-time notifications whenever patients use a Northwell Health facility. If they go to an emergency room, the system will log which facility they went to, what time they were there, and their chief complaint. If the patient has consented it can also drive notifications from a Regional Health Information Organization, Brown said.

"It helps us identify and locate," says Laffey.

Technology Enables the Program

Of course, the programs aim to curb unnecessary ED visits and readmission in the first place. Within 24 hours of discharge, a navigator will call the patient, check on their medication orders, and ensure that their follow-up appointments are made. Navigators sometimes make in-person home visits, too, depending on risk stratification.

The navigators will identify and help to alleviate barriers to care, too. For instance, they might connect patients with programs such as Meals on Wheels or day programs for socializing, as well connecting them with system-offered services, like the diabetes wellness program.

"Our goal is have them connected with their community resources," Laffey says.

If patients need something or have a question, they call their care navigator and getting help immediately, rather than having to wait for a busy physician.

"Patients are calling us directly," Laffey says. "We're answering it in real time with minimum delay."

The Tool Evolves

At first, Laffey says, the tool was extremely basic, built to identify stroke patients who had Medicare, but it's quickly grown to include more conditions.

"The tool grew with us," she says.

It's been expanded, improved, and tweaked, with new versions always providing more functionality. In fact, the clinical and IT development teams meet weekly to discuss how the tool is working and how it can be made better, she says.

"We've talked about even what content is in the drop-downs," Laffey says, adding that the clinical team might ask for something like, "Can we have the allergies listed in the header?"

Laffey says their latest request should be going live within a few weeks: Allowing each of the care programs to see what the other is doing, instead of existing in silos.

"Now we're going to be a true, integrated team on one platform," she says.

She anticipates that such integration so will help to curb duplicate services, assessments, and care planning, and provide a more holistic view of each patient. Laffey also expects the Care Tool and the program it helps to facilitate to continue to expand and grow in tandem.

"We are really kind of proving our worth over time because of our outcomes," she says. "As technology evolves we're evolving with it."

Alexandra Wilson Pecci is an editor for HealthLeaders.


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