Enhancing Patient Outcomes Through Data-Sharing Solutions

We live in an age of data, and sharing patient information between providers is vital to quality healthcare. Even as we acknowledge this is true, it’s uncommon for healthcare providers to share records and medical details with each other unless it’s a specific request. But that may be about to change.

About six months ago, I landed in the emergency room. The registrar approached me with his iPad and gathered my details. Then, he presented me with the consent form to share my data with other care providers in accordance with HIPAA regulations. I am the type of person who really values and respects privacy, and if I didn’t know what that consent form meant, I would have immediately declined. But given my work in healthcare, I knew that consent could save my life one day. It could reduce the time to an accurate diagnosis. It could mean that, if I come here again and I can’t speak for myself, there will be some way for everybody to care for me appropriately because they’ll have access to my medical history and ongoing treatment plans.

I said, “Oh my God, I know exactly what that consent is for!” and gladly signed.

Healthcare providers shouldn’t have to tell patients that sharing data between providers isn’t possible, especially to those patients that have already opted for it at another center for the sake of their own outcomes. If a patient has opted in and consented, it is the job of healthcare operators to view this as a patient right rather than a preference, and we have an obligation to facilitate that right however we can. We've learned that empowering caregivers with HIPAA-compliant technology that makes it easy to track patients’ journeys across caregivers and facilities is the best way to advance practices in our industry and community. That’s what we’ve done at Sherrill House.

Finding a home with few barriers to impactful change

Sherrill House is a skilled nursing and rehabilitation center in Massachusetts, and I joined our team in 2022. My experience up until that point had been in very corporate senior care environments, where I encountered a fair number of barriers. I was the director of nursing services, yet whenever I suggested an improvement, I heard a lot of “No,” without ever hearing why.

That was a big sticking point for me. I am fixated on making improvements and found such an environment very limiting. I was looking for another opportunity, and a conversation with Sherrill House CEO Patrick Stapleton clarified my way forward. Sherrill House is a not-for-profit organization, and because it’s a standalone entity, there are fewer barriers to making impactful change. Above all, the sense of autonomy they gave to any designated leader felt like a strong expression of trust to me. I saw how it could prevent our vision from becoming too personalized to any one individual's abilities and limitations.

All skilled nursing facilities share the same drive to do what’s right, but our model works to build revenue and good outcomes only to invest it back into the organization. Once I understood that, I felt like it was everything I had been missing. I signed on as Director of Nursing Services, and within three months, I became Chief Clinical Officer.

Reintroducing the nursing process into standardized workflows

My niche is clinical programming, and I wanted to touch as many departments as possible. The best way to be a successful leader in a skilled nursing facility is to see and feel how any change in one area affects the whole. Because our departments are so closely connected, I was glad to see that the Sherrill House team had PointClickCare to open lines of communication between care, services, and financial operations.

I wanted to improve our EHR technology to work better with our acute care partners. Optimizing our PointClickCare instance was a good place to start.

We had several challenges with how our existing system was configured. Our inconsistent forms meant caregivers had to scroll through pages of notes to find the information they needed. There was no standardized terminology, either. It was hard to follow up on documentation because everybody described their interventions differently. Transferring patients to different facilities was also tricky because of discrepancies between shared documents. Licensed staff were following the rules but not knowing why, and although they were adhering to expectations regarding frequency and type of assessments and documentation, they often missed the essence of the patient’s situation. These findings were not unique to the facility—in fact, these challenges were similar to what I've experienced throughout my career. However, Sherrill House afforded me the opportunity to enact change, setting my sights on a brighter future with more than a hunch on how to get there.

I wanted to streamline and standardize documentation, and my enthusiasm energized our PointClickCare CSM. We worked to customize our forms and reintroduce the nursing process—assessment, planning, implementation, evaluation, and reassessment—into documentation. We standardized our assessment workflows, making it easy to enter and interpret patient data at every step along the care journey.

Next step: transforming our EHR

Once we’d improved our assessment workflows, we began to examine ways to optimize our EHR. We adopted a suite of PointClickCare products, including PointClickCare Connect, Practitioner Engagement, Secure Conversations, and Document Manager. In doing so, we virtually eliminated paperwork, improved the quality of our documentation, and enhanced communications between nurses and practitioners.

With the success of these changes, I got the green light to further expand our use of PointClickCare. I had my sights set on:

• Nursing Advantage for comprehensive diagnosis-based assessments and clinical guidance
• Performance Insights for visibility into financial, clinical, and operational metrics

Getting a nurse to recall and document what just happened for 20 patients or five admissions while somebody’s at risk of falling and another person is transferring out is honestly ludicrous when the technology exists to eliminate that labor. Nursing Advantage has a structured, click-through documentation process that guides nurses and practitioners through patient assessments, allowing them to enter data faster with increased accuracy and spend more time on bedside care. It offers an alternative to free-form notes, so instead of writing out every action and diagnosis, our nurses fill out standardized checklists, which are easier to complete and process. 

Nurses can assess more patients in less time in Nursing Advantage, and the data they capture is more relevant to billing because the platform prompts them to recall details and points of interest relative to diagnosis, abnormalities, and alerts generated by the data entered by each previous user. Current payment models are designed to incentivize care interventions relative to the patient's needs, so the Nursing Advantage structure is beneficial to achieving better outcomes and capturing justifiable returns. On top of this, clinicians and administrators can easily discern gaps in individual and collective patient care using it in tandem with Performance Insights.

These two PointClickCare modules allowed us to increase automation, expand tracking, and demonstrate the effectiveness of PointClickCare to our executive team.

A smooth rollout leads to decreased hospitalizations and increased Medicare reimbursements

During the roll out, the learning curve was lower than I had anticipated, resulting in fewer errors and incomplete assessments. I tracked nurse productivity in Performance Insights and saw comprehensive assessment times plummet from 30 minutes using paper and our older online forms to 4 minutes and 35 seconds using Nursing Advantage.

Then, I turned to our revenue and quality metrics. In the six months after deploying Nursing Advantage, we saw a dramatic reduction in rehospitalizations. I can trace this progress directly to Nursing Advantage by tracking compliance. When we use Nursing Advantage as intended, every observation triggers a follow-up action. Patients receive appropriate care, and rehospitalization rates fall dramatically. When Nursing Advantage isn’t used to its full potential, rehospitalization rates rise. When one of our units got new staff, there was a temporary uptick in rehospitalizations, but the rate fell again when our new hires settled into using Nursing Advantage as part of their workflow.

I find that rehospitalization is the number one concern of acute care partners and Accountable Care Organizations (ACOs). Hospitals send patients to a facility to be rehabilitated or for post-acute care with the intention of returning them to the community. If those patients end up back in the hospital, it demonstrates that a facility isn’t doing its job. Our success using Nursing Advantage has fortified our relationship with our partners and made us more competitive against other skilled nursing facilities.

We further noted a significant increase in Medicare reimbursements, which is entirely related to more thorough documentation, taking less time to complete using Nursing Advantage. Medicare will only refund costs if the patient meets certain criteria, and Nursing Advantage makes it easy to gather the required documents and show compliance because the standardized checklists use the same terminology.

We also use Nursing Advantage for managed care patients who face strict criteria for private insurance reimbursements. We assign nurse case managers to rigorously document patient procedures and assessments so seniors in our care don’t have to pay out of pocket. We do everything to keep them healthy and fight hard to justify coverage when they need to stay longer than expected. PointClickCare has given us the tools to advocate for them.

Preventing duplicate treatments and facilitating data sharing

Patients aren’t always the most reliable when it comes to recalling what procedures they’ve undergone and what medications they’re using, which sometimes leads to duplicate treatments and wasted time. We now have much more detailed patient histories, so we don’t have to rely on patients to remember everything or second-guess our next steps. A nurse can see that a patient has already received a specific X-ray or that a previous physician has tried a particular medication. We’ve become much more efficient, preventing duplicate treatments that reduce costs and protect patients from unnecessary procedures.

Our increased data-sharing capabilities have brought us into the modern era. The PointClickCare portfolio allows us to collect and share quality data for every patient from the moment they enter our facility to their discharge—and beyond. When they leave our care, we can provide detailed information to their family doctor, specialists, personal support workers at home in assisted living facilities, or emergency room staff as necessary.

Nursing Advantage makes it easy for every member of a patient’s care team—at Sherrill House or elsewhere—to consult a detailed patient history with comprehensive and understandable action items. It’s incredibly helpful to specialists, who can keep track of their patients between visits. It provides healthcare workers at every level a snapshot of a patient at that exact moment in time, with the context that explains how they got there. Automating and sharing documentation with Nursing Advantage and PointClickCare has given Sherrill House the tools to share patient data with our team, healthcare partners, and every healthcare professional who touches the lives of our patients.

In our data-driven culture, having the ability to share this information between providers is no longer an option. It’s critical for a healthier patient and a better patient experience, along with increasing revenues that Sherrill House can reinvest in patient care.