An Orchestra of Care: Transparency for Patients at Home

By Matt Phillion

Real-time visibility into patient care beyond the acute care setting is more important than ever. Hospitals are more reliant on ambulatory care providers as part of the patient’s care journey, and the quality of patient outcomes depends on collaboration between hospitals, postacute providers, health plans, and other organizations. So how do we put data into action for better management of patient populations and outcomes?

“There’s been a lot of discussion around the shift to home-based care,” says Lissy Hu, CEO and founder of CarePort. “More patients want to recover in their home, outside the facility. How do we make that happen?”

If we’re seeing more patients who prefer to recover in their own residence versus at a nursing home, asks Hu, what does that mean for physicians, care managers, or other professionals coordinating these services for the patient?

“For the patient coming out of the hospital and going to a nursing home, it’s basically one-stop shopping. Their doctors, nurses, and bed are there. The oxygen they need is there,” says Hu. But home care still requires things like durable medical equipment (e.g., oxygen and an appropriate bed), nurse visits, and follow-up with the patient’s primary care physician.

“How do we do that in a timely manner?” asks Hu. “If we have the oxygen there, and a doctor’s appointment, but don’t have a home health nurse, if the patient experiences symptoms, everything is more high stakes. All of these things need to be coordinated. It’s part of an orchestra.”

As founder of CarePort, Hu has spent the past decade working to connect hospitals with postacute care providers. “Instead of someone at the hospital having to call around to 10 nursing homes in the area, how do we make that process electronic?” she says. “We can book flights across the world but have very little visibility into the nursing home down the street.”

While hesitancy to enter a nursing home during the COVID-19 pandemic was expected given the challenges the industry faced in 2020, patients expressed a growing preference for home over nursing care even pre-pandemic. This meant that the industry’s focus had to expand into home health agencies, infusion providers, non-emergency transportation, durable medical equipment and home medical equipment providers, and more.

In the last year, CarePort has seen its software used not just by nurses in the hospital setting, but also in physician practices. “It’s been really interesting,” says Hu. “One of the reasons we started to see this is that nurses would transition from hospitals to practices and realize they got to use software [for this task] in the hospital, but back in the physician’s office they have to call around. It doesn’t make sense. So we got pulled more and more into the ambulatory space. When you look at national data, 30% or 40% of referrals to nursing homes originate with physician practices, and that number continues to grow.”

The aging boomer population

“As more baby boomers have aged into Medicare, the preference is that they’d rather recover in their own home,” says Hu. “Obviously during COVID we saw an acceleration to this trend.”

Hu says that the baby boomer generation overall is interested in more information about quality of services. “They’re just used to transparency in the quality of hotels, flights, and restaurants, so when choosing home health or nursing homes, they want to have an understanding of the quality of those providers,” she says.

CMS has progressed in this regard as well, Hu notes, with the emergence of Five-Star Quality Ratings for nursing homes and home health agencies, plus public reporting of vaccination rates at nursing homes. “We’ve brought a lot of that data into our tools,” says Hu. “It’s not just connecting the provider with what’s available. Patients are questioning data on those services.”

Bringing that data into the CarePort platform enables doctors and nurses to identify the services that best fit the patient’s needs. “Not all services are created equal. Different patients have different requirements,” says Hu.

The impact of data

Some of the data included is what Hu calls “table stakes criteria”—whether the provider takes the patient’s insurance, for example. “There’s some baseline criteria, like ZIP code, insurance, clinical needs, and availability,” she says.

Based on those criteria, CarePort can then drill down into quality data. “We take into account the CMS quality rating, which is a good start, but as you read up on nursing home quality, there are pros and cons associated with it,” explains Hu. “For example, the score is blended, including patients who live there and those who are there for rehab or short-term care.”

Some nursing homes excel at custodial care but may not be as highly rated for short-term care. “It’s a different skill set,” says Hu—and with that in mind, patients are likely interested in going to the facility that’s right for them. “Coming out of the hospital, the patient may need to know ‘Can they help my hip get better?’ versus ‘Do they treat pressure ulcers?’ ”

With roughly 20 million referrals sent annually, CarePort is better able to triangulate the right match for the patient. They also work alongside health plans, which have their own sets of quality indicators.

“There are a lot of ways a physician or nurse can look at the availability, and the quality, and enable the patient to make a tradeoff. Maybe he or she wants to go to a specific provider, but that provider is 50 miles from his or her daughter,” says Hu. “It’s about giving the patient that information.”

CarePort has also seen that final decisions on care are increasingly falling not to patients, but to their adult children. This means the nurses and physicians aren’t just engaging with the patient themselves, but with a caregiver who can benefit from the additional data to help them make this pivotal decision.

“We’ll frequently hear: ‘Can you email this to my adult daughter so they can help me make this decision?’ ” says Hu. “It’s almost like sharing hotel results.”

Closing the loop and increasing visibility

CarePort also aims to leverage its software to close the loop on referrals. “It’s not just enough in our minds to get a patient to a high-performing postacute care provider or home-based care provider,” says Hu. “It’s about ensuring this actually happens.”

This means going beyond referring the patient to a home health agency and ensuring that the agency’s care is on point. For example, did the nurse arrive within the time frame specified? If not, the physician is notified and another referral can be made. “This helps with the staffing challenge we’re seeing on the home health side,” says Hu.

While the focus is often on the primary care physician’s or office staff’s role in these referrals, they may not always be the ones making the referral. For cancer patients, this duty may fall to the oncologist’s office or a healthcare plan management team.

The preference for home-based care also opens up many opportunities for growth and innovation, notes Hu. Five or 10 years ago, postacute home healthcare wasn’t talked about on a daily basis in hospitals or physicians’ offices, she says.

“Over time, people started to think about it more alongside an aging population that is living longer and have more of a need for these services,” says Hu. “Then COVID came, and everything around skilled nursing and nursing homes was in the mainstream press.”

Physicians couldn’t get patients out of the hospital because nursing homes were shutting their doors due to COVID-19, and suddenly the C-suite was newly aware of the dependency between the healthcare system and postacute care.

“Now we’re seeing this even more with staffing shortages in home care,” says Hu. “I think we’re going to see much more collaboration, coordination of care, and interoperability in the next five or 10 years.”

With 10,000 baby boomers aging into Medicare every day, providers are taking on more risk, so they have to be more responsible for patients outside the walls of the office or hospital.

“I think this is an exciting time for healthcare—there are a lot of challenges, but we’re going to see big leaps in terms of innovation,” says Hu. “When faced with those challenges, that’s when innovation happens.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at