Demystifying care coordination with Sarah Kivett, Director of Strategic Partnerships, Hospice and Palliative Care of Iredell County, and Jesse Marinelli, Chief Transformation Officer, PruittHealth

Episode 72 October 31, 2023 00:35:36
Demystifying care coordination with Sarah Kivett, Director of Strategic Partnerships, Hospice and Palliative Care of Iredell County, and Jesse Marinelli, Chief Transformation Officer, PruittHealth
The Post-Acute POV
Demystifying care coordination with Sarah Kivett, Director of Strategic Partnerships, Hospice and Palliative Care of Iredell County, and Jesse Marinelli, Chief Transformation Officer, PruittHealth

Oct 31 2023 | 00:35:36

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Show Notes

Introduction

In this episode of the Post-Acute POV podcast, our host, Melissa Polly, senior director of marketing, MatrixCare, is joined by Chris Pugliese, director of product interoperability, ResMed SaaS, Sarah Kivett, director of strategic partnerships, Hospice & Palliative Care of Iredell County, and Jesse Marinelli, chief transformation officer, PruittHealth.

Join the group as they discuss strategies and tips for improving care coordination between hospice and skilled nursing facilities (SNF). Chris begins by outlining the general challenges that post-acute providers face, Jesse and Sarah then describe their experiences with managing hospice and SNF relationships and how they’ve overcome obstacles in care coordination. Listen to their conversation.

Topics discussed during today’s episode:

  1. [00:34 – 01:13]: Introduction to the podcast topic, guest, and healthcare technology in hospice and skilled nursing.
  2. [01:50 – 03:40]: Chris describes the challenges of communicating between different care settings.
  3. [04:36 – 06:02]: Chris talks about the current technology gaps in the healthcare industry.
  4. [06:50 – 08:35]: Chris explains simple ways to utilize technology to minimize human error and increase productivity.
  5. [09:18 – 12:02]: The group discusses determining your interoperability strategy, deciding goals for the future, and using technology to improve workflow.
  6. [12:59 – 14:13]: Chris details the first certified health information networks.
  7. [14:22 – 15:43]: Sarah and Jesse describe their background.
  8. [16:15 – 19:31]: Sarah and Jesse discuss the delivery network in their different organizations and the main factors involved.
  9. [20:18 – 23:29]: Sarah and Jesse examine areas where they have experienced challenges in coordinating communication between hospice agencies, skilled nursing facility partners, and organization members.
  10. [24:02 – 28:27]: How Sarah and Jesse identified the problem and overcame these challenges.
  11. [29:14 – 32:37]: Chris details the value of direct communication between providers and Sarah discusses the strategies she used to support partners.
  12. [33:00 – 35:08]: Jesse identifies the tactics he used for business growth and improving communication and Chris concludes the episode with his key takeaways.

Resources

Disclaimer

The content in this presentation or materials is for informational purposes only and is provided “as-is.” Information and views expressed herein, may change without notice. We encourage you to seek as appropriate, regulatory and legal advice on any of the matters covered in this presentation or materials.

©2023 by MatrixCare

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Episode Transcript

Speaker 1 (00:02): Welcome to the The Post-Acute POV podcast, our discussion hub for healthcare technology in the out-of-hospital space. Here we talk about the latest news and views on trends and innovations that can impact the way post-acute care providers work. We'll also dive into how technology can make a difference in today's changing healthcare landscape for home and facility-based workers and the people they care for. Let's dive in. Melissa (00:34): Hello everyone, either good afternoon or good morning, depending on what part of the country you're from. Very excited about this topic today around demystifying care coordination between hospice and SNF or skilled nursing facilities. I'm excited to have Chris Puglisi join us. I'll do an introduction for him, but in case you're not familiar with MatrixCare, just a quick highlight. We are an EHR provider and we cross over multiple care settings. You may have known us as Brightree previously or as MatrixCare today, but either way, we're committed to innovating for the post-acute space. We like to tout that most of our technologies are designed for clinicians by clinicians, and we are a multi-class winner. (01:13): So without further ado, I'd like to introduce Chris Puglisi. He's been working with post-acute providers and their technology for over 10 years. He now serves as the director of product interoperability across all of our care settings within MatrixCare, Brightree, and overall the ResMed SaaS business. He's a leading voice in the post-acute space. He sits on several committees including post-acute [inaudible 00:01:37] working group, along with other committee positions through Commonwealth Health Alliance and Avion. Without further ado, Chris, I'd like to turn it over to you because I know this is a hot topic for everyone to be able to smooth in these transitions between care settings. Chris Puglisi (01:50): Thanks, Melissa, and good morning or good afternoon everyone. Really excited to be here today and to join you all in this discussion, which I think in a lot of ways is underrepresented, although it is something that I know all of you out there providing hospice and palliative services are coordinating and working with nursing facilities pretty much every day. So before we get too far into the specifics of that relationship, I did want to bring us back up and just talk broadly about the challenges of working between different post-acute providers. So taking the hospital out of it for just a moment here and really looking at the challenges that post-acute providers across the continuum face. First, unlike our friends in the hospital and ambulatory areas, our patients, our residents, they are in these different care settings for longer periods of time on average. Another thing that's fairly unique in the space is you've got multiple providers with patient responsibility, assessing and caring for patients at the same time. (02:43): And that's particularly key in the topic for today as we have palliative practitioners or clinicians for the hospice going into nursing facilities to provide their services. And then lastly, and this bring us back into our hospital friends, but all of our care settings have a much heavier reliance on referrals coming from acute or ambulatory settings rather than walk-ins or methods of getting patients and referrals in that you might see at the acute ambulatory level. So we have some just unique challenges that we have to address and that they are particularly acute when we're working together in our long-term and post-acute continuum. So to kind of frame up those problems, you can put them into two buckets. Now these buckets are big and they encompass a lot, and we'll talk a little bit more about those shortly. But generally, inefficient care transitions. How you onboard a patient that is coming from a nursing facility or referral or other out of hospital or post-acute referral source, as well as the coordination between your entities. (03:40): As I mentioned, if you're talking about an individual that is a resident at a facility of some kind and you are a hospice or a palliative clinician going in to provide services, all the work and labor to coordinate documentation and share findings and updates and whatever else is largely manual in many cases and entirely without reimbursement. Presenting just a general operational challenge for organizations to work efficiently. This is a permutation, one permutation, a very diverse care journey that a patient could have. But generally, you're going to have a patient that's moving from a higher acuity to a slightly lower acuity and lower cost bed in the nursing facility. They're going to have their care provided in the facility and should the patient be eligible for hospice services, hospice benefit, the hospice or maybe prior to the hospice being brought in, the palliative clinician will be engaged with the nursing facility receiving number one, a referral to start out with. And then coordinating care on an ongoing basis. (04:36): And again, lots of different permutations. It may not be a skilled facility. We could be talking about a scenario where a patient is in an assisted living facility and the hospice services are needed. So lots of different varieties of this, but I think broadly there's a path that follows. And the big focus here is this non-reimbursable coordination occurring after that, often less than smooth transition of care. So where we want to get to is where a hospice provider working with a nursing facility and on the other side of the course as well, that we've got a seamless data exchange for key pieces of data that are relevant to patient care or in some cases just the documentation that's being generated by each respective provider patient being shared freely across so they can be absorbed into each other's records. (05:16): And so all of the major EMRs out there that are supporting facility-based care, we've tried to list as many of them as we could here. Most can support some level of this. So we know that there's these technology gaps in healthcare broadly. Some of it is access to technology. Some of it's just the technology hasn't been extended down to post-acute providers. And so often we find post-acute is left out of a lot of these big health tech discussions and we're kind of on the tail end picking up things as they become more massively available at a cheaper cost. Our providers, whoever still have the same needs as you would see in other settings where you do tend to see more of the health tech discussions happening and new technologies being deployed. And that's an ongoing interest as we see more and more care being moved out of hospitals or post-acute spaces, where the overall costs are lower. (06:02): However, even in the acute settings, even in working with their post-acute partners, whether that's a facility or a hospice location, there's still a heavy reliance on faxes and there's lots of solutions that are trying to solve these problems. But again, a lot of them are focused up in that acute and ambulatory setting. So we have this kind of push-pull where there is a general need, especially as the interest in post-acute settings rises as a way of getting patients to a lower cost setting where they can still receive the right level of care, but the technology isn't necessarily there to support an immediate shift or pivot to a more home-based or facility-based provider relationship. And this is some data from a survey that MatrixCare performed a few months ago, surveying a wide variety of providers, physician providers. Now this is all across the continuum. (06:50): So there are facility providers in here, there are hospitalists, there are primary care doctors. So it is a wide swath, but broadly, I think everyone can see the trend here is that a huge amount of coordination of referrals is all being done with very analog means. So we have electronic facts is probably the leader right here, the plurality, but even so that is not necessarily helpful or meaningful information to action on in a workflow driven environment using data. And the rest of it, the other almost 50% is phone call and traditional paper faxes. And that is a broad challenge to seamless connectivity as well as a patient experience that is unified across these settings that again, may be overlapping in their care. And that's especially of a challenge here in our discussion today around the interaction between nursing facilities and hospices. You've got this simultaneous care being provided, but a lot of the processes are paper-based that leaves them open to human error. And of course human error can lead to bad outcomes. It can lead to dings from your Medicare auditor, so on and so forth. (07:53): Where we want is to get that orange slice that is the minority here into a much more active part of anyone, your average facility or hospice rider's workflow. Everything should be electronic if we can make it that way and save everyone time. So I'm going to take the next chunk of time here to talk about how you as a hospice provider can engage your nursing facility providers. I will say that this playbook is very, very similar if not the same to what you might see working with a hospital. Certainly the relationships are different. We've talked about this, a couple of times now. The overlapping care is a dynamic that is different than you might see at a hospital, but the broad strategy can be employed both ways. (08:35): So when you're working with your nursing facility partners, think of them the same way as you would your other referral sources. In many cases, in fact, I would say almost in all cases, a lot of the same technologies are available for you to utilize. So step one, and this seems like it's self-explanatory, but decide what you want to accomplish. There's lots of different avenues you can pursue in an effort to improve connectivity and data exchange and operations, working with your nursing facility partners. And you have to have a goal that you're setting out first that you want to achieve. And that goal is not necessarily technology. That is an operational goal that you have as an organization that will make X, Y, Z better. We'll get to X, Y, Z in a second. (09:18): As far as that goes, think small. So have a big goal. But in terms of your milestones, small wins are better than no wins. And I think we all know that in healthcare, things don't always move quite as quickly as we might want them to. And so aiming small, aiming for continuous growth, continuous expansion and improvement is going to be a much better strategy than trying to solve for the whole world. So aim small, set a goal, and then set smaller milestones to achieve that goal. Once you've hit all those milestones and achieved your goal, set a new goal and keep moving on from there. This is a pivotal one, and I think this is one that the gap here really drives off the fact that a lot of the federal funding, federal assistance, general resources available just based on the reimbursement models and the size of organizations in the post-acute space, there's not always a person that can focus on all the technology options that are available to them within their EHR. [NEW_PARAGRAPH]The EHR can tell you till the cows come home, all the things that they can do, but that sometimes just needs to be asked. The first thing that you'll have to do once you've formed your plan, your goal that you want to achieve and kind of strategy to go about it, engage your EMR. All of your EMRs in the hospice space have some level of capability for electronic exchange. The same is true at the nursing facility space. The major EMRs that operate in that area all have some manner of electronic exchange you'll find very similar to what you might see at a hospital. Those are technologies that you have an opportunity to use to deliver on some of your goals and execute on your interoperability strategy when working with your nursing facility partners. So it is important to remember that the nursing facility EMRs that are out there in many cases are as sophisticated and in some aspects possibly more sophisticated than what you might see at some of the hospital levels. (11:02): So when you are building out your interoperability strategy and you're deciding what your goals are, what's going to be the outcome, the financial outcome? Because at the end of the day, we're all operating businesses here. Interoperability should be delivering you flow driven efficiencies. The data is not just being piped from one place to another. You should be able to define a real financial implication from superior operation using technology to drive forward data exchange in your workflows. So for example, if you're thinking about models around lowering costs at hospice with palliative service on the front end, a nursing facility interaction and the engagement from a palliative organization earlier in a resident stay at a nursing facility can earn you some of those savings in the short term, as long as you can get the palliative practitioner into the facility early enough. So thinking along those areas and strategies you want to approach in terms of how they're going to improve your financial outlook, either through direct means like efficiencies or less direct means like superior patient care, better ratings, so on and so forth. (12:02): Once you've established your strategy, once you've gotten your different tools in place, you've engaged your EMR, you've been engaging your nursing facility partners. Use your capabilities that you've delivered to improve the workflow, the compliance, whatever else it might be with your facility-based partner, use that to grow your business, use that to go to other facilities and engage them and share with what you've accomplished with some of your other partners. This is an opportunity to stand out. And one thing that we do know is that if you can make things easier for an organization, you become a primary referral source or a target referral source for them or referral destination rather for them. And lastly, and this is outside of just more of the direct action planning, but there are a lot of shifts that are rapidly occurring, especially at the federal level when it comes to changes in thinking and changes in regulation around interoperability. (12:59): So just some quick examples. We'll try and stay away from too many acronyms, but TEFCA, which is the Trusted Exchange Framework and common agreement, which is a cures act, I don't believe it's cures act. It's a federal program driven by the ONC that is creating a rules of the road for exchange across the entire country. So how vendors and organizations and providers can exchange information freely across the country without limitations on what EMRs you might be using, what networks you might've joined and so on. And that is moving. That's moving fairly quickly. And the first TEFCA certified health information networks are starting to appear, I guess their applications have been accepted and they're starting to move towards the process of being certified. So these are all things that are happening right now that could dramatically change how you're working with your facility partners as well as some of your other referral sources. (13:54): But you have to be paying attention to all of these as they come forward so that you can take advantage of them, so you can leverage the opportunity in a way that is meaningful to your teams and to your patients, and get ahead of those before they become commonplace and everyone has them and it's no longer a differentiator for you and your organization working with different referral sources. (14:13): So with that, we're going to shift now to our panel for today, and Jesse and Sarah, if you'd like to join us. So I'll let Jesse and Sarah introduce themselves starting with Sarah. Go right ahead, Sarah. Sarah Kivett (14:22): My name is Sarah Kivett and I'm the director of strategic partnerships here with Hospice & Palliative Care of Iredell County. We are located in North Carolina. We are a not-for-profit, so we standalone in our outreach to hospitals. All of our referral sources are skilled facilities. We do have a strong palliative care program. Our palliative care census stays around, is average at about 450, and our hospice census is around 225. So we do have strong relationships with our local hospital and provide the palliative care team there at that hospital. So transitions from inpatient to post-acute we are very involved in. Chris Puglisi (15:08): Great, thanks Sarah. And Jesse, go ahead. Jesse Marinelli (15:10): Hello everyone. My name is Jesse Marinelli. I'm the Chief Transformation Officer for PruittHealth. PruittHealth is a cross continuum organization. We operate in Maryland, North and South Carolina, Georgia, and Florida. We operate skilled nursing, home health, hospice, assisted living, pharmacy therapy, I-SNP, D-SNP, you name it, we kind of do a little bit of everything. Palliative care as well. My role inside the organization, I'm a technologist by trade, so my role in the organization is to use a data-driven and technology approach to maximize efficiency and performance. Chris Puglisi (15:43): Awesome, thanks Jesse. And I hope from their introductions, everyone knows why we wanted to have both Jesse and Sarah on because it's two very different experiences that I think are important for everyone to get a feel for as we go through our panel discussion today. So I'm going to go ahead and kick it off with the first question, and I'd like to start with Sarah with this one. I'm going to ask the same of Jesse in a moment here, but Sarah, can you go ahead and just describe the delivery network your organization works in and just some of the different actors involved? I think you mentioned it already in your introduction, but let's deep dive into that and talk about how you've built relationships and where you'd like to move within your network. Sarah Kivett (16:15): Yes. We have a very strong palliative care program that has really taken off in the probably the last six years. We do have a strong relationship with our local hospital. We have found that that was a really needed area. We found that a lot of our referrals from that hospital were going straight to hospice with a very short length of stay. And so we identified and worked with that leadership to try and help our patients who in our rural area are also our neighbors and our neighbors families. And so to try to help identify these patients with chronic illness more upstream, to help them stay out of the hospital, which is something that would really help our hospital in their 30-day readmission rates as well. (17:07): So we could see these patients more, help to transition them and follow them with our palliative care services, whether in their home, their traditional home or in their skilled nursing home. And a lot of these patients that we saw may be hospice eligible in the hospital, but wanted to transition to a skilled nursing facility and utilize those skill days and see if there were any goals that they could meet on therapy days. And so our palliative care program is able to follow them into that skilled facility, which helped us to realize how strong our relationship with the facilities really needed to be. Chris Puglisi (17:52): To kick the same question to you since you operate in a little bit of different area because you all control a huge swath of your own domain, so tell us what the delivery network looks like in the Pruitt world. Jesse Marinelli (18:04): Sure. To put it succinctly it's complex. PruittHealth operates our own skilled nursing and assisted livings, and we also operate our own hospice and palliative care. So we have that part of our delivery network where we're staying inside the PruittHealth continuum and our hospice service providers are going and seeing patients inside our skilled nursing locations, and they may be transitioning and leveraging our medical supply network or our pharmacy network. So we've got that PruittHealth continuum, that's that one branch of our care delivery network, but then we also provide hospice services to external skilled nursing and assisted livings. So they each have of course, their own individual expectations and processes for hospice and palliative, and so we have that part of the network to handle. (18:50): And then of course, you have your coordinating with your external HMEs and your pharmacies for the patients that are not in our PruittHealth field nursing locations. And so you have to meet those needs as well. So you need to manage those relationships. And let's not forget the attending physicians for the hospice and palliative patients and coordinating care with the attending physicians. Then of course, last but not least, we think we've talked quite a bit about the hospital systems and working with their unique standards and expectations. So you've got really a lot of different possibilities for your referral management system. It comes to maintaining where you may be getting referrals from, and then once you have brought a patient on service, you've got a lot of different relationships to manage the individual services that you need to provide. Chris Puglisi (19:31): Yeah, I think actually this is a fantastic point that you're both making, which is everyone's a little bit different. So it's one concept. Hey, it's a transition and we're going to coordinate and exchange some information, maybe it's a little bit manual, but it's got to be done through 30 different methods because of all the different entities that you're working with, which presents its own challenge. There's not a homogenization of capability or even just process since a lot of these processes are paper-based, so left to individuals to sort work out and decide what works best for a given organization. Post-acute care is generally on the receiving end of what those processes are supposed to be, which prevents its own challenges, especially with the hospitals too. And the same again is true if you're a hospice receiving referrals from a facility. I think Jesse does have one advantage in that they can at least standardize that process for that interaction best they can. (20:18): Okay. Obviously there's all these different moving pieces for both of you, and I don't want to be too doom and gloom here, but let's talk about some challenges that you both have faced because even in maybe more upstate like Jesse's where you can control a lot of the situation, there's going to be challenges of coordination and human errors and things like that. So let's just talk about some of the areas that you've really had challenges coordinating your hospice and nursing facility partners and organization members, or let's go for any kind of key challenges. And let's start with Jesse this time for this call. Jesse Marinelli (20:44): Well, I mean, as you mentioned, we have somewhat of an advantage in that we operate our hospice and our skilled nursing locations, and so we can kind of mandate the way that that relationship works, but that's still not without its challenges. Ensuring that we get required documentation onto the SNF patient chart, on the skilled nursing patient chart timely for survey compliances is a big challenge. We've got a large number of patients in coordinating that, across that large patient, both internally and externally. It's a time-consuming and a manual process, and there's some technology capabilities that can help with that. But then you have the tricky part of making sure that everybody is familiar with them, is aware of them, is comfortable using them, and doesn't default back to the tried and true method that is manual and time-consuming, but is more a friendly approach because they're familiar with, let's call that challenge one. (21:34): Coordinating care with the attending physicians. We are our physicians that operate in our skilled nursing locations. They do not work for PruittHealth. They're community physicians. And so of course coordinating care with those physicians is tricky. Most of the time the physicians have MPs that are making the rounds, and so communication breakdowns can occur there. It's a constant communication stream that needs to be maintained. That can be tricky as well. And I would say the third one is probably the duplication of orders. That's a problematic challenge. We need the order in hospice, we need order in skilled nursing. And again, there are technology solutions to that, but getting people to use them and adopt them has been challenging. So I would say those are the three ones I would highlight. Chris Puglisi (22:13): So Sarah, same question for you. Let's talk about some of the challenges you've encountered when you've been working with your nursing facility partners, both from the hospice and the palliative sides. Sarah Kivett (22:21): Yeah, I agree with a lot of what Jesse is talking about. Those orders are really tough to be able to obtain, to be consistent. I know that a lot of [inaudible 00:22:33] still use paper, still want paper. A lot of the physicians that we have, or many of the skilled facilities that we have, have rotating providers that go through and see their patients. So we can take orders over for them to sign and you've missed them by one day and they're not coming back for 10 days. So then you're just in a hold mode. I think that our medical records, people's eyes just slide up and they think, well, if we could send that electronically and there was an electronic signature, then they could look at it whenever and send it right back to us. And it's really... We are searching for people sometimes to just get signatures, plans of care, all of those things signed in a timely manner, that we need to get them signed. So that's a real challenge for us. Chris Puglisi (23:29): We know that there's some challenges, and actually you guys both raised some things that I wasn't even thinking about. Namely, that kind of roving physician. You can't always get ahold of receiving orders from two different entities that even when they're related under one business operation is still... Different EMRs, a huge management nightmare. So given some of these challenges, I know both of you have started working towards this, so I think you'll have some answers here, but tell us a little bit what you've deployed in effort to combat some of these challenges. And it doesn't have to be technology, but just how have you tried to attack these problems? Sarah Kivett (24:02): One of the things that we have done is that engaging our skilled facilities and our assisted livings is that we have invested in a clinical liaison and she or he is a nurse and they have assigned certain facilities and they are establishing a very close working relationship with those skilled facilities. So the leadership of the facilities as well as the medical assistants, the pharmacy techs, they are familiar with that nurse. And if they have questions at that time, then she is there daily. She is in these facilities on a daily basis. The other thing is education. It's very important that we provide education on palliative care, what we can provide, the services that we can provide to partner with them to help maintain these patients within the facility, trying to help decrease emergency room visits or hospital admissions. What we can do to help coordinate conversations and goals of care, conversations with family members, because oftentimes they're not really sure what is the best thing to do. (25:23): I know a specific example is that I had a lady in the community to call me and I said, what can I help you with? And she said, I don't really know. I don't know what my mom needs and I don't know what I can do to help her, but I need to do something because what we're doing is not right and I don't even know where to start. So to be able to help facilitate conversations and to learn about being available to talk with families and help them to navigate a lot of what's going on with chronic illness in this latter stage of their family's life, I think is something that we have tried to really engage our skilled nursing facilities with doing. (26:08): And with that comes the need for better communication and how do they reach out to us? We want to establish a way for them to not pick up the phone or try to scramble around, can't remember our fax number to fax us a referral or we want that to be more automatic and more streamlined for them because that's also going to benefit their workflows and how efficient that they are. Chris Puglisi (26:37): You provide value, you show the nursing facility the value that you're providing by doing right by the family and the resident, and that's something that should be very meaningful to everybody here is that we're trying to illustrate to the facilities. As a hospice, you're trying to show the facility that you are providing value, in the same way that you would if you were working with an acute or ambulatory provider. So I think that's a great kind of note here for everyone to take away from that. Jesse, why don't you go ahead and how you've tackled some of these problems with, again, a slightly different angle than Sarah has to. Jesse Marinelli (27:07): Yeah, so from an internal, our hospice to our skilled nursing, one of the best ways we've found to be able to communicate information back and forth is to allow our hospice offices to have access to patient records at the point in time that that patient is transitioning to hospice. So our hospice providers are able to actually log into our guild nursing MatrixCare system only for patients that they're authorized and that we have obviously applicable documentation for, and get that information themselves. And so it allows them to be able to see both sides, and so that improves the transparency of information and allows for those open lines of communication without having to take some of the extra steps that you might have to do with an external provider because you don't have access to their system. That's something that's been extremely helpful in allowing our hospice and our palliative NPs to be able to do that. (27:56): We're also looking at some other technologies that are outside some communications technologies that allow you to send forms to resident family members, to patient families, to providers that would allow for electronic signatures and technology solutions that would kind of overcome some of those communication barriers when it's difficult to get ahold of somebody but electronically contacting them can be easier. Those efforts are early in phase and have yet to bear a ton of fruit at this point. Chris Puglisi (28:27): I know that you're still working towards that one, but let's pull on that one for just a second here. So I think that's a really good point that your approach is hovering over, which is when you're part of one organization, and if you're working really closely too, so Sarah, you may have some relationships like this as well, but it's much less of a formal, here's the doctor's order, we're sending you a referral. It's kind of a call down the hallway or email inside of the internal office email saying, hey, so-and-so, does your team have any room for this patient in our B wing? And it's much more ad hoc, which the communication, if it's appropriately using some sort of secure messaging tool, which sounds like you guys are assessing, that may also be one of those really valuable things where it's not necessarily the high-minded interoperability. (29:14): Here we're exchanging medications and data and documentations. It's the how can we facilitate that realtime conversation between the case manager at the nursing facility and the case manager at the hospice? And make them on the same page in a way that wouldn't necessarily be indicative in some of the more analog ways like a fax or even just a CCDA, like a direct message, an attachment with some data on it. So when we really start talking about these nursing facility referral sources, and Jesse, this is more the hat you'll wear for talking outside when your hospice are going to other nursing facilities, but when you look at referrals and your case mix broadly or referral mix broadly, there is a kind of changing position, and I think Sarah referenced this already, where you have the patients that are going out of the hospital, they're probably pretty darn close to hospice, but their bed days are cheaper at a nursing facility. (30:04): And so you have hospitals interested in working with facilities to move patients down to slightly lower acuity. When you look at that kind of dynamic, how do you see your business strategy incorporating this pipeline of patients that are really moving from facilities and then overlapping with hospice right afterwards, with maybe some palliative care in there too? How is that fitting into your larger referral source strategy? Because you've got to woo those people as well. You've got to woo hospitals, lots of people that you want to pay attention to make sure you're demonstrating your value. So where does that stack up for your long-term strategies for both of you? Sarah Kivett (30:36): Well, one of the things that we have really embraced is the work that we're doing with our local ACO, because there are still several facilities within our community that those primary care physicians are the ones that are going to see those patients in some of our facilities, so not all of them that have this rotating provider that I mentioned earlier. So having that communication, we do electronic referrals with those physicians in that physician network with that ACO, and have done that for a few years now and has gone very well. So when these physicians go into these skilled nursing, they want that same type of communication and ability to be able to make those referrals and to be able to see those notes. That's one of the things that we really want to provide to be able to work with our skilled nurses. (31:39): That's one of our strategies that we are working on for them as well as being able to provide an easier way for the skilled nursing to be able to get their orders signed. When our palliative care providers are seeing a patient, they're just like a consultant that goes in, the patient's not in hospice yet, so they may be writing orders or we may be doing pain management, and our providers have to sign everything that in a way that those skilled nurses and that facility and their regulations must be done. So trying to look at how efficient we can be from our side to assist and help meet the regulations of those skilled nursing as well, because we are a guest in their facility, and so we really want to be able to not be a hindrance of what they need to be able to get done and to make things easier and simpler for them. Chris Puglisi (32:37): I think that's a really good term. You're a guest and you want to make sure that you're being gracious guests going in, and that's how you're going to build these long relationships that are going to be a significant pipeline for you guys as you move forward. Jesse, same question actually. I was saying maybe focus more on your external providers, but I'm sure there's similar dynamics internally too. So let's hear about that, how you're planning to grow your relationships between your different entities. Jesse Marinelli (33:00): So when we look at business growth, we take your standard and strategic approach of SWOT analysis, we flip it on its head. We identify what the weaknesses are for our particular referral source that we're trying to gain a relationship with, and then we identify the strengths that we possess that address those weaknesses. So we first try to understand how we can fill a need, what it is that we do that is complimentary to their particular business strategy, and then we try to explain our value through that method. And so that may be a source explaining to them our overall continuum that we have available. So we provide services across a large portfolio that may be explaining that we have palliative care and we can supplement your resources in your location so that you have a strong presence that's available and is easily accessible, or maybe a customer service situation that they need assistance with that we can fill a need on or some sort of a consulting or advisory capability. (33:56): So we try to identify what their needs are and we try to come to that conversation, inform that we understand where their problems lie, and we understand how we can be a partner to them to address those problems and work together in that partnership to deliver a better outcome. Chris Puglisi (34:12): Yeah, I think that's, again, building on what Sarah said as well, but also bringing in the fact that every single facility is a little bit different. It aligns with the population that it's serving and they're going to have needs that may be unique and identifying, showing them that you know their world and their business as much as yours is another great way of approaching that. And for Jesse, where his team can control a little bit more of it, targeting those problems in a way that is honed for each of their locations. So that's some awesome insight there as well. (34:41): I hope that everyone takes away the changing landscape for post-acute providers, means that this stuff is no longer just, oh, we can do without it. You kind of need to have a plan for how you're going to be working with these different entities that are in your network, and execute on that plan to deliver superior care and efficiencies for your organization as the change continues to happen. So thank you all. Thank you especially to Jesse and Sarah for taking the time to share their knowledge with everybody today. Have a great rest of your afternoon. Speaker 1 (35:08): That concludes the latest episode of The Post-Acute POV podcast. We have a lot of guests and topics coming up that you won't want to miss, so be sure to subscribe. To learn more about MatrixCare and our solutions and services, visit matrixcare.com. You can also follow us on LinkedIn, Twitter, and Facebook. Thank you for listening. Be well and we'll see you next time.

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