Tracking High-Risk Patients to Support Care Coordination

Tuesday, February 14, 2017 - By: Hixny

When Ann Marie Tripp, Director of Transitional Care Management at Adirondack Health, wanted to track high-risk patients after they left the Saranac Lake Hospital, she thought Hixny first.

Adirondack Health logoTripp specifically wanted to know if any of those patients ended up in another area hospital within 30 days of their visit to Adirondack Health, signaling gaps in transitions of care.   Working collaboratively with Adirondack Health’s IT Department, she asked Hixny to send her discharge event notifications whenever these high-risk patients sought emergency department (ED) or inpatient care elsewhere.

Hixny can send event notifications in three ways: to a provider’s electronic health record system; by DIRECT, Hixny’s secure messaging service; or via the Clinical Message Center (CMC) on the Hixny360 Provider Portal.  For Tripp, giving her access to the CMC was the best solution.

Mahgan Town, Business Analyst at Hixny worked with Tripp to set her up and now she simply has to click on the CMC tab while using the Hixny 360 Provider Portal to retrieve her event notifications.

“This is a first for Adirondack Health and for Hixny” Town said. “No other hospital receives notifications in this way.  This is another example of how we work hard to stay at the forefront of technological innovation and patient care.”

Tripp has received about 5,700 event notifications, including ED discharge notifications, ED reports, inpatient discharge notifications and inpatient discharge summaries, from several different hospitals since July.  They received nearly 1,000 during the month of December alone.  She said she has found them valuable in improving care and efficiency.

“We are able to reach out to our high-risk patients that have been discharged from other facilities to ensure outpatient care needs are met and follow-up has been scheduled,” she said.  “It also helps monitor our readmissions and emergency room utilization, which in turn reduces healthcare costs in our region.”