Community Placement—Extending Care Across the Continuum

Susan: Welcome to Patient Flow Podcast. Today we're speaking with TeleTracking's Product Manager, Tom Perry, and Director of Market Development, Karlin Miller. They will be sharing their thoughts on TeleTracking's newest solution called Community Placement. Community Placement is expanding TeleTracking's reach beyond the walls of the hospital and into the post acute space. Tom, Karlin, welcome.

Tom Perry: Thank you.

Karlin Miller: Thanks.

Susan: If we can start off, if you could each just give our audience a brief overview of your backgrounds.

Tom Perry: Sure. I'll start. My name is Tom Perry, I'm a Product Manager, I've been with TeleTracking since 2001, so for quite some time. Today my role is the Product Manager for the Capacity Management Suite. Over that period of time, I managed and launched a number of different applications into the market. Prior to that I had various technology and process re-engineering roles in the advertising industry, in manufacturing and logistics as well. So a common thread for me has always been streamlining communication and workflow through visibility, but also forecasting to find new ways to optimize processing.

Karlin Miller: All right. My name is Karlin, Susan, and I am a nurse by trade. My background is a little more clinical in nature. I had spent the past 24 years in the post acute and long term care arenas in various roles. Some of my experience includes serving as the owner and administrator of New Horizons Care Homes. Most recently I was the Director of Post Acute Care for a sizable CCRC that offers skilled nursing, personal care, assisted living, home health and hospice. I also currently serve as the President in the Partners in Personal Care organization.

Susan: Wonderful. So Karlin, you really have first hand experience of what that post acute space is. Community Placement is an exciting development for TeleTracking because it's really expanding our reach into the post acute space and really covering the full continuum of care. Could you describe the operational impact this is going to have to health systems and why this solution is really the next step in TeleTracking's overall journey?

Karlin Miller: Sure, Susan. From a clinical standpoint, I believe that this is certainly a key piece or what I would even refer to as a missing line, if you will, in closing the loop. The product enables a quality acute to post acute care transition, which is far superior to the current process. Community Placement creates a seamless pathway between the hospital and the skilled nursing facility, acute rehab facility, or really any other post acute offering. The pathway promotes continuity of care, which as care providers, we all know that continuity is key for providing positive outcomes. We're seeing a significant change in the relationships between acute facilities and post acute facilities. There has never really been much integration between the two. Both have operated very independently historically. Now with the Bundled Payments for Care Improvement initiative, or as it's commonly referred to, BPCI, hospitals are being pushed to assume greater risk for the care episodes. This risk extends well beyond the acute care discharge in the walls of the hospital. Hospitals are now looking for quality strategic partners within the post acute space to devise integrated care delivery models. This effort is aimed at decreasing readmissions and ultimately achieving better outcomes. It's actually a great thing. It's a positive impact for patients and will ultimately lead to better quality of care. A large factor in this vetting process in creating these partnerships is, the development of these partnerships will hinge on how easy is it to transfer patients from the acute care arena to the post acute facility.

Tom Perry: Yes, Karlin, what you're saying is that healthcare is not only delivered in the hospital anymore. So a patient's journey is going to include visits to a physician, to specialists, outpatient venues, urgent care centers now, and even facilities for rehab and long term skilled nursing. So TeleTracking, part of our journey is to help out with that patient's journey. And we've helped throughput and patient flow in the acute setting. We can extend that competency outside of those four walls into the post acute venue. The patient's journey is going to continue beyond discharge from the hospital, and we want to ensure that that journey takes an efficient path to positive outcomes.

Susan: Thank you both, and that leads me to my next question. What impact does this have on the acute care providers, the post acute care providers, and most importantly, the patients and families that are receiving these types of services?

Tom Perry: One thing I can highlight for both is some operational discipline to really measure and constantly improve that process of having a patient go from the acute care setting to the post acute setting. For those acute care providers, that also gives them an opportunity to open up more capacity for more patients, sooner than they could before. And for the post acute providers, Karlin spoke about this earlier, is visibility and also the ability to create a tighter relationship within the healthcare network. And for the patients and families, the impact is certainly less wait time. 

Karlin Miller: That's a great point, Tom, and to spin off of the time factor, I believe that the impact is substantial for several reasons. Perhaps the most prominent is, in fact time, which also results in lost revenue. As the proverbial phrase goes, time is money, and this is no exception. From the time a patient is referred to a physician to a post acute facility, the current process can be cumbersome and full of unknowns. The hospital's discharge planner can spend hours, and in some cases days, trying to find an accepting facility for a patient. The process often includes several phone calls, many electronic messages via patient referral software, emails, text messages, et cetera. Obviously, this can be a frustrating process for providers, but it's exceptionally frustrating for patients and their families. So the scenario often plays out like this. We have an often elderly individual with compromised health navigating in what's likely unchartered waters, if you will, with limited or no experience with the discharge-transfer process. We then sprinkle in the element of the unknown. So the patient's often being told, "We're not sure where you're going or when you're going, but as soon as we know, we'll make arrangements to get you there." If you've ever experienced this personally or witnessed it, it's certainly a stressful time that Community Placement can prevent.

Susan: Well, I guess for the acute facility, by being able to effectively move that patient to the next step in care they now have that bed open for somebody else who needs care. The post acute facility, it's a benefit to them, they're filling an open bed and certainly for the patients and families, it's streamlining it and reducing stress and anxiety.

Tom Perry: Absolutely.

Susan: So finally, could you talk a little bit about how the technology keeps up, how this works and how this is really helping overcome these challenges that we've just been discussing? Tom Perry: The two key ways that Community Placement really impacts this process are around visibility and communication. So now a health system has transparency to understand, which beds are available, which beds will become available beyond the four walls of their hospital, into their post acute care partners. So they can make decisions, more educated decisions, in order to get that patient to those venues. For the post acute faculties themselves, I mentioned this before but it can't be stressed enough, operational discipline. The more that you can have a process be repeatable, you can also take that process apart and continue to fix it. And Karlin, you have some experience with this. You talked about how the process can be somewhat disjointed on the communication side, and even on the operational side. This now gives them this discipline to be able to follow some practice in order to have better outcomes. 

Karlin Miller: To expand upon that a little bit, Tom, absolutely from the post acute perspective, based on my experience and based on conversations that I've recently had with post acute management level folks, the post acute space welcomes this direct link to referral services with open arms. Community Placement provides the post acute provider several valuable tools. It's a direct link to a key referral source, which provides a consistent referral path aiding in census stability, and census stability obviously is a revenue source. Secondly, by streamlining the referral process, it helps with staffing in simplifying the role of our admissions coordinator. We take a lot of moving parts and we kind of condense them down into one. It also prevents transfer miscommunications, and transfer communications are certainly very common, and very costly, and time consuming. And last, but certainly not least, it will improve patient outcomes by creating that integrated care delivery that we talked about earlier.

Susan: Well, this is certainly an exciting development, as we've been saying, really across the board for acute, post acute and patients, and it's exciting to see this type of focus on delivering positive outcomes. Thank you both so much for joining us, and we look forward to having you back to talk about how this all progresses.

Karlin Miller: Thank you.

Tom Perry: Thank you, Susan.