Ensuring that an individual’s needs are met across various areas of care can be complex and overwhelming, but with correct tools in place, organizations can achieve whole-person care and do it well. Facilitating interoperability between care providers is key and necessitates the need for investing in the right technology to make it happen.

Eva Bering is vice president of operations at Landis Communities, a five-star, full service, live-at-home facility in Lititz, Penn. It offers a 114-acre continuing care retirement community (CCRC) campus, has 825 recipients of care and 550 employees. Here on CareThreads, she offers insight as to how their organization has been able to leverage technology to provide holistic care to its patients.

Q. What has been the impact of the trend toward whole-person care at Landis?

We reviewed our upstream and downstream approaches to patient care, specifically to better manage continuity of care cycles. We have strong relationships with area health systems and work with several payers across the care spectrum. But competition is growing and we quickly realized we needed better integration with partners to create even stronger network partnerships.

Q. Were there any other challenges you addressed?

Pennsylvania has seen a tremendous increase in utilization of managed care due to federal and state efforts decrease costs. But with only 103 skilled beds, we face a competitive disadvantage. We needed tools to support our value by demonstrating improved outcomes and maintaining healthy and established relationships with referral partners. But we also needed to ensure we’re expending our resources in the best way possible. We’re leveraging technology to accomplish both goals.

Q. In what specific areas does technology play a significant role for Landis in coordinating care?

We’re integrating more closely with acute care settings to automate key phases of the referral process and improve transitions of care. We expect more comprehensive, shared outcomes and return on investment from the technology, as well as a competitive advantage due to improved communications and better processes.

Having greater visibility of patients across the continuum of care helps us maintain a high quality of care at a lower cost. Thus, leveraging integrated technology solutions provides efficiencies throughout the journey of patient from pre-admission to post discharge.

Q. How does integration/interoperability technology translate into a competitive advantage?

Competition in our area has increased tremendously, in terms of both managed care and the impact on the healthcare system. Lancaster General Health is the major referral partner, but other hospitals are infiltrating the geographic area, which gives us even more incentive to leverage what we offer, knowing we only have 103 beds.

Health systems are narrowing their preferred networks to provide more value. As they’re looking at cost, quality, readmission data, length of stays and standardized clinical pathways, data helps us highlight our strengths and the quality of our services to acute care providers.  With data collected through technology, we’re able to provide metrics and costs per patient per day.

Q. Can you share with us some insights from the data?

We’ve determined that our re-admission rate runs in the range of 4 percent to 5 percent. Our length of stay has gone from 26 days in 2016 to 17 days in 2017; with decreased length of stay leading to decreases in cost. Admission-discharge activity has increased, which is a good thing. All of this underscores the importance of the technology and the positive effect it’s had on our organization.

In addition, the gains in productivity mean the nursing staff is more efficient, which is obviously extremely important. As nurses become busier with more complex cases and engaging the residents they’re caring for, efficiency and the integration of information becomes more important. Technology drives all of that for us at Landis Communities.

Q. How much of that improvement can you trace to automating processes?

We have seen the referral base from the main referring health system go from 67 percent of our referrals a year ago to 76 percent of our admissions today. We attribute at least part of this increase to being able to enter a patient’s medical records directly into shareable electronic format to ensure streamlined care across the spectrum. Further integration through Netsmart supports inbound and outbound submission of data to referral partners and those involved in the patient’s individual care.

Q. What does the future hold for Landis and leveraging technology?

We’re placing great emphasis on moving forward with increased use of our technology. It provides the framework to get the information we need and to use the data in a way that’s meaningful.

We’re looking at possible connections to pharmacies and therapists, so that information goes directly into the patient record and there’s no need for a separate attachment or log that must be downloaded in Excel.

Another goal is to use our data to perform predictive modeling that can project patient length of stay. This would help us manage costs and go beyond potential 30-day re-admission to examine the continuum for a 60- and a 90-day re-admission.

We’ll continue focusing on operational efficiencies. We feel that will become just as important as care efficiency, especially as we experience increased case complexity, decreased revenue and competition for referrals.  We want to see where our referrals come from and where they go so we can look at continuity of care, decrease fragmentation and errors, and increase efficiency.

Learn More in This Recorded Presentation

Interoperability: The Journey to Whole-Person Care features Eva Bering and AJ Peterson, vice president of interoperability at Netsmart. The free recording covers how to identify challenges and opportunities associated with coordinating care between care settings, and understand key components and strategies for coordinating care across an increasingly diverse landscape of providers.