Lightbeam’s population health management (PHM) platform includes HL7 ADT messages and feeds that transmit critical patient demographic information. The specific information helps providers stay on top of daily hospital utilizations and see which patients were admitted or discharged from a facility within 24 hours of an event.
ADT Feeds Help Care Managers
Why is this information important? First, it enables providers to know who, out of their patient rosters, has been in hospital care over the past day, week, and even month to ensure that they receive the proper post-discharge care. By using these ADT feeds, care management teams can reach out to these patients via phone to monitor post-discharge behaviors and make sure to schedule follow-up office visits as needed.
Second, with certain patient populations, such as Medicare beneficiaries and CMS reimbursements to providers tied to hospital re-admissions, it’s key for care management teams to know who has been hospitalized for what conditions. Post-discharge care can be established to help prevent those patients from being hospitalized again within a 30-day period.
Finally, with one out of every two adults in the U.S. having a chronic disease and one out of every four U.S. adults having two or more such conditions, using ADT feeds can help providers and care teams better monitor these patients. This information can help them track their patients’ current state of health, take note when a hospitalization may have occurred related to a particular chronic ailment, and then determine the right level of outreach needed to continue treatment and potentially prevent other conditions from occurring or worsening.
The Biggest Challenge
The biggest challenge for healthcare organizations as they manage population health is the conversion and delivery of actionable information to the appropriate resources. The Lightbeam application for ADT feeds operates through Lightbeam’s cohort builder solution and is designed on the HL7 standard, making it interoperable with many of the electronic health record (EHR) programs used by healthcare organizations across the country.
The cohort builder helps providers and care management teams divide their patients into population sub-groups based on certain attributes such as risk, condition, and event (such as ADT) and then analyze that data based on the prioritization of need, giving clear guidance as to where care management and other efforts should be focused.
What’s even better is that providers don’t need to be coders or have extensive IT skills to operate the Lightbeam cohort builder. In just a few steps, care providers can initiate complex queries against patient data to identify specific individuals who qualify for specific evidence-based care plans with the goals to help reduce costs, improve workflows, and most importantly, improve patient outcomes.
The hustle and bustle for providers to deliver the best possible care to their patients, particularly those most at risk for hospitalizations and with chronic conditions, will always be there. Healthcare technology is meant to assist industry stakeholders – including patients, providers, care teams, hospitals, and payers – with the means to deliver better care while lowering costs. Technology shouldn’t be an obstacle, especially to those providing patient care, and at Lightbeam, we’ve developed solutions that allow physicians and healthcare teams to do what they do best – deliver the best possible care to the right patients at the right time and improve the quality of life for all the populations of which they serve.
Maha Salah-Ud-Din, a Senior Advisor at Lightbeam