Key Project Achievements:
The initiative to connect Case Management Agencies (CMAs) with Admission, Discharge, and Transfer (ADT) data has yielded significant achievements, demonstrating the potential of ADT data as a vital acuity tool in long-term care. The pilot project successfully:
- Established a reliable system for delivering user-friendly daily ADT data to participating CMAs, enabling them to access timely patient information.
- Provided policy and process recommendations, proposing system changes to incorporate ADT event notifications and work queues within the Case and Care Management (CCM) system.
- Empowered CMA pilot participants to effectively utilize ADT data for identifying and responding to Critical Incident Reports, enhancing their proactive care management capabilities.
- Facilitated the identification of collaborative opportunities between CMAs and Regional Accountable Entities (RAEs), fostering a more integrated healthcare ecosystem.
- Successfully incorporated stakeholder feedback through regular monthly meetings and surveys, ensuring the project’s responsiveness to user needs.
- Culminated in the completion of a comprehensive report by the HCPF, summarizing findings and recommendations from the Connect Case Management Agencies (CMAs) to Admission, Discharge, and Transfer (ADT) Data Pilot.
Project Summary and Outcomes:
The 6.13 pilot project, connecting Case Management Agencies (CMAs) to Admission, Discharge, Transfer (ADT) data, operated from January to December 2023. Seven CMAs participated in this crucial initiative, receiving daily ADT hospital data through a secure HCPF portal. This data served as an invaluable Acuity Tool For Long Term Care, enabling CMAs to identify and monitor agency-associated members’ hospital visits. By leveraging ADT data, case managers were promptly alerted to potential shifts in members’ functional needs, required services, and possible critical incidents. This proactive approach significantly enhanced the effectiveness of case management and improved the overall member experience.
Feedback collected through monthly participant meetings and surveys by HCPF staff highlighted numerous positive outcomes, solidifying the value of ADT data as an acuity tool. Participants’ input led to a system change request aimed at integrating ADT notifications and a work queue into the CCM system, streamlining workflows and improving efficiency. Access to ADT data demonstrably improved outreach efforts and strengthened communication between case managers and their members, directly enhancing member experience. Case managers reported feeling more equipped to conduct thorough and timely follow-ups, leading to improved coordination of discharge planning and a smoother continuity of care.
The project unequivocally demonstrated the mutual benefits for both members and case managers through the integration of ADT hospital data. For case managers, ADT data acted as an essential acuity tool, providing vital information for better care coordination and active participation in discharge planning. Ultimately, this enhanced access to timely patient data contributed to improved health outcomes and a higher quality of care for individuals receiving long-term care services.
Project Metrics:
Seven diversity-focused grants were awarded to Case Management Agencies (CMAs), with 85.7% of grantees classified as diverse and recognized as small businesses. Pilot participants completed 12 monthly surveys, each comprising an average of 10 questions across key areas: ADT data quality, Critical Incident Reporting, and RAE-CMA Coordination. Respondents also contributed examples of ADT follow-up activities, providing practical insights into data utilization. HCPF staff engaged in 12 monthly meetings with pilot participants to discuss and evaluate outcomes related to ADT data quality, progress in Critical Incident Reporting, and RAE communication. Over 30 hours were dedicated by HCPF project leads to gathering, documenting, and organizing stakeholder feedback for the ADT project. Despite a temporary disruption due to a nationwide data outage in June and July 2023, HCPF successfully distributed ADT data for 290 days between January 26, 2023, and December 31, 2023. Analysis revealed that the ADT data distribution positively impacted an average of 704 members each month, showcasing the significant reach and potential of ADT data as an acuity tool in long-term care management.
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