The team here at Cantata Health is excited to discuss the importance of cultivating modern care coordination as you get hit with increasing financial and regulatory pressures. This blog will speak to these industry shifts and explain how our new Referral Portal can help you thrive as a skilled nursing facility today and into the future.

Introducing our new Referral Portal:
As discussed in our recent webinar, our new Referral Portal is a CRM solution that streamlines the process of screening, approving, and onboarding new residence. We’ve actually been servicing the acute care market with this solution for some time now and after seeing great results we’re excited to bring it into the long-term care sector.

Your facility is continually having to gear up against mounting regulatory and financial pressures. We believe that now is a critical time for you to modernize the way you manage referrals. We hope to demonstrate just how big of an impact you can see by empowering your clinical liaison.

This modernization makes to possible to make more educated, faster decisions during care coordination, as it takes a data-driven approach to marketing. Our portal can help you leverage a paperless process for resident transfers. It helps you stand out in your network by transitioning residents effectively. It can help you forecast occupancy rates and plan appropriately and it also helps you identify high-risk residents and avoid unnecessary costs, which is increasingly important with PDPM coming.

Acute hospitals are getting hit with all-time high capacity rates and due to Medicare regulations. They need to get outgoing patients to the lowest-cost care area as safely as possible within about 24 to 48 hours. On the other hand skilled nursing facilities and long-term care facilities are facing low occupancy rates, shrinking operated operating margins, and evolving payment models (PDPM).

To maintain reimbursement rates, facilities will need to evaluate prospects through a new lens.

The logistics of care coordination and all its moving parts:
When a hospital determines that an outgoing patient needs long-term care, these hospitals provide documentation to receiving facilities in a variety of forms. Some fax, some call, some use electronic platforms to distribute referrals throughout their networks. And since so much critical patient information must swap hands during the care transition process, communication needs to be concise.

Ideally, receiving facilities can quickly pull together a complete patient story including things like insurance demographic information and clinical history to really determine whether or not that individual will be a good fit for their facility. Then they can determine accurately whether or not that prospect will be a good fit. They can avoid unnecessary costs and also reduce Hospital readmissions. To add another layer of pressure to the care transition, process facilities are fighting to remain preferred providers in order to continue getting referrals from surrounding hospitals. When an acute facility is ready to relocate a patient, the hospital case manager typically communicates this to multiple SNFs in their network.

Cultivating an efficient centralized care coordination process:

There are three key initiatives to strive for:

  1. Streamline your process
  2. Select the right residents
  3. Gather data and track trends

For the first goal; the traditional care transition process often involves a lot of phone tag faxing and guesswork. We’ve seen that resources and opportunities get lost in translation. It’s our goal to reiterate that as this industry gets more and more complex facilities will need a better method. It is now to replace paper processes with an electronic platform. Often, the facility with the most speed wins referrals as we mentioned earlier. LTC facilities rely on acute referrals to maintain occupancy and as networks narrow, facilities need a way to stand apart from the competition and secure their spots as preferred providers, so the faster a clinically liaison can complete the preadmissions process, the more likely they’re referring hospital will send future residents its way.

Secondly, when clinical liaison has less paperwork to manage and fewer back-and-forth trips to take, they can focus on business growth and strategic initiatives nurturing their most valuable lead sources.

Thirdly an airtight preadmissions process makes it easier for facilities to collect the specific information about prospects that can impact Medicare reimbursements under PDPM. By using a system that centralizes disparate data sources. Your team will also have a much easier time accessing historical information.

It’s definitely time to replace paper processes for fewer errors and less wasted time. Consider a system that integrates with your EHR to reduce redundant efforts and work to leverage workflow engines and setup approval cues.

How our Referral Portal can help you accomplish these three goals:
This new product streamlines care transitions in a few different ways. We like to focus on the customizable skip logic within the referral portal. That feature only shows users what they need to see, when they need to see it. So we ensure the clinical liaisons are asking all the right questions and gathering the data that’s needed and nothing more.

The clinical liaison doesn’t have to make the decision of which questions to ask or not. We present them with the questions that they need. There’s also the bi-directional, EHR agnostic, integration so you can integrate directly with NetSolutions, or other systems to reduce redundant data entry.

There is also advanced notification routing to ensure seamless communication with referring admitting and clinical teams. And we provide improved documentation by getting your information to you.

Let’s get into a few more specifics about these aspects. EHR integration – that reduces the redundant data entry as mentioned before and it also enables concurrent workflows so you can have somebody in the referral portal that signing off and approving on a referral that information carries into the prospect list and is able to be seen while the liaison still in the field.

There’s no need for liaison to stop and send an email, make a call, or potentially have to fax a whole bunch of paper. Or in some cases even having folks having to wait until they leave on returns to the home facility to bring that paperwork back for folks to review. Help streamline it by while that liaison still in the field your person either at the facility or this could be a central person for a group of facilities doing some additional validation while the clinical liaison is still gathering information.

We also have a be mentioned Traditional High show type of logic to help reduce the cognitive load on the liaison. They don’t have to make those decisions. One questions for example in the screen under ‘our history hospitalization’ page is that if the prospect had not had any other prior hospital stays in the last 60 days.

Under the ‘see any more questions,’ when they answer, “yes,” we asked them about previous day’s the name the type the admit dates discharge date reasons and similarly. We have that set up for the LVAD that if the prospect is not on an LVAD the liaison doesn’t need to go through and determine what questions to ask if they say, “yes.”

We’re looking to find out and have them answer about the insertion date if they have a CI B and other things. But again, if they are noted that LVAD, they just they just see the next question and then to also help with the party it also helped with the advanced notifications basic. We’re trying to improve communication between your stakeholders and not having to have people stop at interrupter.

Work in order to make sure everybody’s informed. This way, when referrals are completed and depending upon the state of that refute that referral we can send emails to only notify the folks that need to be notified upon that stay the referral and can save time as we mentioned before about that driving back and forth or stopping make a phone call or send emails once they leaves on completes a referral or even if it’s in process.

The appropriate folks are notified via email because we’re collecting all this information. We know the status of all referrals across either one facility or if you have multiple facilities, we can provide daily or weekly email audits so that we can notify key stakeholders on the facility or regions KPIs and general performance.

Along with that in the past of using paper and you you’re getting audited by some group. You’ll need to produce your paper reports and spend a lot of time just really pulling up the information in the referral portal. You can just run some reports provide the information we have current users that that have expressed how easy they’re auditing is now because they can just access the portal get the information they need and relatively easy as that.

We’d like to reiterate that responding quickly to referring hospitals is key, but not if it leads to an ill-fitting resident, no one benefits. Like when a facility accepts a resident that requires more or different care than it can provide.
SNFs also need a quick and effective way to determine if a prospect is an ideal clinical social and financial fit for their facilities and to do so, we recommend that you equip your clinical liaison for the comprehensive yet simplified method for conducting the pre admissions process that way.

That way, they can easily spot patients need for things like specialized equipment, medication, or services. All of which facilities really need to have the means to provide prior to admitting a new resident. And then after that and hospitals know that they can rely on facilities with history of meeting residents with those clinical needs.
The Referral Portal can help your facility accrue best at residence with features like a comprehensive pre-reg questionnaire and advanced screening tools. The Referral Portal has some advanced screening tools at least help make it easier for your clinical Liaisons to spot red flags and patient records. Helping them avoid residents that could jeopardize their facility financially reputationally or even legally.

Skip logic that can help empower clinical Liaisons ensuring that they’re asking the right questions; drilling down into the resident aspects that will impact the success of their stay and help easily identify who to admit and who to deny. And we’re going to focus on a few different pages around our social history and neurological assessments.

On the social history form, the Referral Portal asks various questions about where they live and their and their advance directives and smoking status and alcohol intake. If unknown, the liaison can just move on and answer their psychosocial questions and other flags, but when the answer “yes,” we pop open a large substance abuse assessment to ensure that all the right questions are being asked and that you get all the information needed to be able to make the most informed decision about this prospect, and whether or not to admit them into your facility.

The next page is around the neurological specifically and Behavioral Management. The product has several questions so your SNF can be informed on suicidal ideation, though as with others, if unknown, they can just move on to the next section. If there were thoughts of suicide, we make sure that the liaison is asking the prospect appropriate questions so that your decision makers have all the information they need then accurate information so that they can make those decisions as to decline or to admit the resident.

Referral Portal also has a watchlist for certain prospects that you know you may not want to admit to your facility for one reason or another. Residents can be added potentially due to past behavior in a facility among other reasons.

And then the product has logic in here to help alert the liaison where if they enter certain matching criteria like their name and date of birth and gender and other criteria. That you get alerts that the referrals on the watch list and to control supervisor before moving forward helping ensure that your Liaisons and your resources are putting their work on referrals that you’re that you’re going to want to be able to admit and be able to stop them before they you know, potentially progressed too far down a referral that you’re not actually going to have any chance of bringing your facility.

The Referral Portal also enables clinical Liaisons help gather information. They need up front to ensure proper reimbursements such as comorbidities surgical histories and wound documentation. And additionally, the proper insights to select. The best fit residence facilities can set themselves up to achieve better resident outcomes, which can lead to healthier reimbursement under PDPM.

For wound care, the referral portal offers a couple of different ways to be able to enable your facility to capture information. Generally, yes/no questions are asked, but we also enable the liaisons to select on the body where different items are and give the information about the type and the length so that it’s not just a ‘yes’ – know that there’s more actionable information that you have for determining the fit for this prospect. We also enable discrete like individual comorbidities to be selected as far the incoming prospect and we’re able to capture them and we’re going to be able to report on them and provide insight to your folks.

Before this resident or potential resident even enters your facility, you may have admissions coordinators or other folks that assess the needs of the potentially incoming. And we can provide that information through this portal to those to those stakeholders that need the information live when they need and even if a liaison still actively working on a referral these folks would still have access to through the portal to be able to get that information.

With Referral Portal, there’s no handwritten notes or misunderstanding about what the user put in. It’s very clear what they’re checking off as they’re going through the portal and it helps facilities have a clear communication and provides an audit Trail for that med list as well. So that said we know when items were added.

How Gathering and tracking trends like referral history acute facility or physician allows facilities to get a holistic view of their most and least active partnerships.

This kind of insight helps medical liaison spend more time nurturing. Their symbiotic relationships and it can also help them catch and remediate downtrend before historically reliable referred goes off the map over time and then on the flip side by pinpointing which hospitals have never passed many referrals your way.

It’s beneficial to track resident Trends, especially with the shift to value-based care. It’s absolutely critical for facilities to understand what their residents need and how well they’ve been able to actually meet those needs and keeping track of this kind of data is the first step towards improving clinical outcomes. Then, down the road once you’ve established a process for efficiently accepting your best fit residents and you’ve reached an uptick in successful clinical outcomes as a result.

You’ll also need a way to prove it to referring entities because really in this day and age, data and survey results speak louder than anything else to hospitals. Referral Portal can provide you and your team insights more in-depth to help use all this information.

Referral Portal can provide you the timeliest, most accurate information so you can make the right decision and can help you align your specialty services with the care demand. So if we see an increase demand and your referrals for certain health issues, there’s certain sort of needs those incoming residents have, you’ll be able to see that through our reports and through these through these insights?

You can make the decisions proactively before you get overwhelmed with residents rather with a certain condition and you not having the right facilities or the rights of the services available to be able to meet that need and then once you’ve established a process for efficiently from the best fit residence and reap the uptick in the outcome as a result will need a way to prove it.
One more way to help do that is you can look at month-over-month and look at your occupancy. You can look at historical Trends over months or over years to help plan your plan your facilities scheduling, and other resources as needed.

Let’s recap on some of the key points:
We covered namely how big of an impact your pre admissions process can have on your facility’s financial well-being. As we’ve discussed, the Referral Portal is designed to help support the three key pieces of advice we’ve cover here. Ask yourself these three questions:

  • Do you capture and respond to referrals as efficiently as you could do you have a bird’s-eye view into referral patterns?
  • Can you currently predict prospect speedy PDPM reimbursement rates during the pre admissions process?
  • Does your facility ever accept residents at can’t properly accommodate medically socially or otherwise and with that said we are now going to go into a Q&A session?

Take time to consider these questions and the ability of your facility to take new residents in a speedy way that encourages the “right” type of resident for the types of care you can provide. Learn more about the Referral Portal today!