Gloria Shields knows that some hospital networks have hundreds of providers to choose from when they discharge patients who need at-home care. As director of transitional care at Bowes In Home Care, she wants the Crystal Lake, Illinois home health agency to stand out in a crowded field.

Shields says a professional staff and excellent service are difference-makers. Another advantage: PreparedHealth’s network, a HIPAA-compliant electronic platform used to quickly accept referrals and coordinate patient care. Previously, the agency relied on faxes and phone calls to collect patients’ medical and insurance records and confirm availability.

“It’s a competitive edge to be on the platform and to be part of a facility’s preferred provider network,” she says. “It’s a much more efficient way to send referrals and share documents and it’s made us a more responsive partner.”

Rallies provide real-time updates

Shields began using Prepared Health in 2017, as a nurse liaison at Centegra Healthcare’s Huntley and McHenry, Illinois hospitals. She worked with two case managers who oversaw newly discharged patients from the total joint replacement and congestive heart failure Medicare bundled programs.

Shields used the “rally” feature on Dina to electronically update patients’ progress. Rally reports included recaps from home visits, vital signs, photographs of wounds, and lab results, all shared in real time with patients’ healthcare teams. Doctors and other team members were immediately notified of any changes in conditions.

“There was better communication with the care team which led to quicker response times, expedited orders and responses to carry out interventions at home,” says Shields. “We found it to be the ideal platform for improving patient care.”

Building new partnerships

In March, Bowes began accepting electronic referrals from other clinics and skilled nursing facilities, including a large new partner who only works with providers on the network. Since Bowes was already on the network, the transition was seamless and they were able to immediately accept electronic referrals.

In August, Centegra expanded its use of the platform to manage the discharge and referral process for all patients. Bowes has accepted 182 referrals from Dina and Shields expects the numbers to increase as more providers join the network.

Sending referrals upstream

In November, Bowes began using the platform to proactively send out electronic referral requests for patients who needed to move from home health to skilled nursing.

“We want to be partners in the continuum of care, recognizing when a patient needs a higher level of care and facilitating a referral on their behalf to community partners, where they can receive skilled nursing and rehabilitation,” she says.

Although few upstream referrals have been accepted, Shields believes that, too, will change.

“There’s not really a team commitment among different levels of post-acute care providers but I’m hopeful Dina will help change that,” she says. “As relationships develop and more providers see the job we do, we think they’ll see the value in building a partnership.”


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