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.
Alexandra Wilson Pecci is an editor for HealthLeaders.