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To help with social service referrals, Advocate uses a digital platform, which has a robust database of local community agencies that can help patients with food insecurity and other social determinants of health, or nonmedical factors that impact health outcomes. The technology app allows for closed loop referrals. When a health care provider refers a patient to a participating food pantry, the food pantry would document in the app that the patient came to the pantry and the provider would be able to monitor this access. Advocate Aurora’s post-acute network currently has more than 35 affiliated SNFs across Illinois. To identify potential SNFs to collaborate with, the health system’s accountable care organization (ACO) determined which facilities Advocate Aurora hospitals refer to the most due to location, quality scores, and other factors. To join the network, SNFs had to agree to a variety of quality-related requirements, including having a licensed, registered nurse (RN) on-site 24/7 and establishing effective discharge planning processes.
Advocate Aurora’s Improvement Charter Care management staff at Advocate Aurora decided to focus on improving longitudinal care management for BPCI patients with sepsis because of the large volume of BPCI patients affected by this diagnosis. In addition, they wanted to build on the work they had already done to improve care coordination for BPCI patients. A multidisciplinary team, with representatives from inpatient, ambulatory, and post-acute, began to tackle the challenge by looking at existing processes and tools used to coordinate care for sepsis patients — from hospitalization through discharge to post-acute and/ or home. The team found a lot of variability in the transition process for sepsis patients, with no consistent protocols or tools used. The effectiveness of handoffs between sites was primarily dependent on the care managers’ communication abilities and approaches. “Some care managers would have specific communications to hand off between places, while others were not as proactive in their communications,” Aufderheide said. “So, it is a person-dependent process. Because we are all currently on different EHRs, it is difficult to make it a system-driven process.” To address the shortcomings in the existing process, the multidisciplinary team developed an interim, paper-based longitudinal care pathway for BPCI sepsis patients to guide care sites in documenting and exchanging needed information during care transitions. This initiative aligns to TOC standards 2 and 4. The longitudinal care pathway is also being used to inform the creation of a soon-to-be-launched longitudinal care record in Advocate Aurora’s EHR.