Care Pathway Heart Care Program Adjustments

Care Pathway Heart Care Program Adjustments

Role: Manager Of Transition Care

The Care Pathway Heart Care program aimed to provide enhanced cardiopulmonary rehabilitation for patients post-discharge by integrating remote patient monitoring directly into the health system’s electronic medical record (EMR). As this program was managed through the system’s owned home health agency, I played a pivotal role in streamlining processes and improving overall patient care. Key steps taken include:

• Developing Dynamic EMR Tagging Protocol: To ensure smooth transitions for patients opting into the Care Pathway, I developed a dynamic tagging system within the EMR. This tagging process automatically translated patient data into the discharge planning tools and referrals, eliminating the need for manual documentation. This reduced the risk of missing patients and improved data accuracy.

• Proactive Patient Enrollment and Referrals: The system was designed to alert the team to patients who were mid-assessment and potentially eligible for the program. By enabling proactive referrals, we were able to increase the program's acceptance rate and get patients into the system earlier, ensuring timely care and treatment.

• Addressing Home Health Capacity Issues: Given the capacity constraints of the owned home health agency, I established a partnership with a key overflow provider to handle additional patient needs. This collaboration ensured that the same protocols were followed across both agencies, maintaining continuity of care and preventing gaps in the patient’s journey.

• Long-Term Patient Tracking and Monitoring: To ensure long-term continuity of care, I worked on creating a process for tracking and monitoring patients beyond their immediate episode of care. This effort ensured that patients received the same provider post-discharge from one hospital episode to the next, fostering trust and improving outcomes.

• Development of a Skilled Nursing Facility (SNF) Network: In parallel to the home health efforts, I led the development of a SNF network tailored to the needs of cardiopulmonary rehabilitation patients. This included creating SNF-specific protocols for patient referrals, monitoring, and communication between the health system and SNF providers, ensuring consistency in care.

• Integrated SNF Protocols for Continuity of Care: Protocols were developed to ensure that the CarePathway Heart Care program was seamlessly integrated across both home health and skilled nursing facilities. This holistic approach aimed to provide uninterrupted care for patients, regardless of whether they were discharged to home or a SNF.

Impact:

• Improved Program Adoption: The streamlined process and proactive referrals led to higher acceptance rates and earlier enrollment of patients into the CarePathway Heart Care program.

• Enhanced Continuity of Care: Long-term tracking, consistent provider assignment, and SNF network integration ensured that patients had seamless care from one episode to the next, improving patient satisfaction and outcomes.

• Optimized Resource Utilization: The overflow partnership helped alleviate capacity issues, ensuring that patients received timely care while maintaining high-quality standards across all care providers.

• Higher Operational Efficiency: The dynamic tagging and integration with discharge planning tools eliminated manual documentation, improving workflow efficiency and reducing errors.

• Better Patient Outcomes: Continuous monitoring and long-term care management allowed for more tailored treatment plans and improved cardiopulmonary rehabilitation results.

• Improved SNF Network Efficiency: The development of a tailored SNF network and specific protocols enabled a smoother transition for patients needing skilled nursing care, improving care coordination across facilities