The Rhode Island Quality Institute (RIQI) and Integra Community Care Network announced the launch of Care Management Alerts and Dashboards, an innovative new service enabling healthcare providers to proactively coordinate care and support for 140,000 individuals throughout Rhode Island.
RIQI’s Care Management Alerts and Dashboards provide near real-time data about patients admitted to and/or discharged from acute care hospitals and their emergency departments across the state. Through the Integra Care Management Dashboard, clinical staff at Care New England, Rhode Island Primary Care Physicians Corporation (RIPCPC), South County Health, and care management staff at Integra now have quick and easy access to important data to improve care coordination, time-sensitive follow-up, education, and support for their patients.
“These services help providers stay connected with others delivering care to their patients in a timely way that prevents patients from falling through the cracks when seen in different care settings in the state,” said Laura Adams, president & CEO, RIQI. “With this information delivered directly to them, Integra’s care teams have the ability to prevent avoidable hospital and emergency department readmissions that often result when care is poorly coordinated.”
Each time an Integra patient is admitted to or discharged from a participating hospital, skilled nursing facility or emergency department, Integra’s care teams receive information alerting them about their patient’s status. In addition, care teams can view more detailed information about current as well as past admissions and discharges for their patients.
“For a practicing primary care physician (PCP), there is nothing more important than knowing where your patient is at any point in time and what problem needs to be addressed. The dashboard created by the RIQI is a major advance in achieving this important goal,” said Al Puerini, MD, chairman of the Integra Board of Directors and president and CEO of the RI Primary Care Physician Corporation. “Now, a PCP can open this dashboard and instantly know when his/her patients are in an emergency department or admitted to the hospital. The dashboard includes their diagnosis and exact location. This permits us to be more directly involved in their care allowing instant communication in real time with providers, patients and patients’ families. The physicians at RI Primary Care are already experiencing the incredible benefits of this innovative service provided to us and our patients.”
Access to this information provides several key benefits to both providers and patients:
- Care teams can reach out to the hospital, emergency departments, and/or patient to provide information from the practice and facilitate coordination of care during and immediately after an admission
- Follow-up visits can be scheduled sooner
- Readmissions can be prevented through discussion of the care plan and review of medications
- Education can be provided to the patient about when to call the office first
“It’s common sense that doctors can provide the best care when they have a patient’s full medical history in front of them,” said Senator Sheldon Whitehouse, who helped launch RIQI while serving as Rhode Island’s Attorney General. “I commend the Rhode Island Quality Institute and Dr. Puerini’s team at Integra for joining forces to make our health care system work better for Rhode Islanders.”
Integra’s care teams can also watch trends over time for specific patient panels and track outcomes of its comprehensive care management approach that puts the patient first. This is particularly valuable for following their patients with chronic conditions or an unusually high number of hospital visits.
“RIQI’s Care Management Alerts and Dashboards support Integra’s goal to constantly provide a better patient experience, better health care, and, most important, better health,” said James E. Fanale, MD, EVP, Physician Enterprise and chief clinical officer for Care New England Health System, and Integra Community Care Network. “Dashboard data is near real-time and we have created a process to notify providers’care teams when a patient’s status has changed so they can respond appropriately and immediately to help them manage their health and focus on preventive care.”
Integra’s nurse care managers monitor patients with diabetes daily and reach out to them routinely to discuss proactive disease management approaches. The goal is to help them better cope with their conditions and find more enjoyment in life.
“Having alerts and access to records from other facilities enhances our ability to manage care for our patients,” said Ruth Scott, director of Care Management for the Integra Community Care Network. “It can also help with medication management as well as lab and radiology results, particularly when there are multiple providers and locations. I can’t say enough about the importance of being able to track patients as they transition through the continuum of care.”