In addition, the center provides support for patients with chronic diseases or conditions and offers a number of community health programs aimed at promoting good health and well-being.
North Country HealthCare faces a challenge simply by the size of the geographic area it covers, serving communities from Lake Havasu in the west to Springerville in the east, and from Payson in the south to the Grand Canyon in the north. Care managers are assigned to clinics in each of the 14 served communities. These care managers coordinate an integrated team that works with high-needs patients who have complex or multiple chronic conditions, such as diabetes, or behavioral health issues. They also work with patients who experience social determinants challenges that impact their health or patients who visit the hospital and hospital emergency department (ED) for treatment that could be delivered in a primary care setting. Through care managers, patients receive health coaching to make sure they attend appointments and receive support with any necessary transitions from the hospital.
When North Country HealthCare was set up to receive Alerts, patient panels were uploaded according to the clinics where patients received care so that care managers obtained Alerts for their assigned patients. Alerts are received at 8:00 a.m. daily regarding any discharges that occurred within the past 24 hours, and care managers ensure that clinic providers have the latest information to see which patient cases are complex or have a higher risk for readmission.
Pearlmutter says that the Alerts are typically used as a trigger to start a series of follow ups that make provider-patient time more valuable, and this enhanced transition of care ensures that once a patient leaves the hospital, they are ready to resume care at their primary care facility. She says that Contexture, Arizona’s health information exchange (HIE), has been invaluable with these transitions back to a patient’s primary care provider, adding that transitions can be a risky situation for patients with multiple problems that could lead to a hospital readmission or further medical problems.
Alerts delivered “in the right place at the right time” not only assist in helping patients avoid readmission, but they can also lead to life-saving care, Pearlmutter said.
For one patient, an Alert may have saved her life. After receiving an Alert about her patient being discharged from the hospital, a care manager quickly realized that the patient had cardiac issues with aspiration that had led to aspiration pneumonia. The Alert allowed the care manager to be involved earlier and to follow up with a referral to a cardiologist.
Pearlmutter has seen the Alerts from Contexture improve the ability of North Country care managers to serve its patients, and she refers to the enhanced system of care as, “the perfect example of technology and the human touch.”
“The HIE is such a beneficial system that’s helping our team receive the most efficient information we have ever seen,” she said. “From the Alerts to the follow-ups, all of the data has become more valuable and allows us to provide better care. We are so happy to be connected to Contexture and look forward to all of its accomplishments to come!’