When North Country HealthCare started receiving Alerts in 2016, they had little idea of the impact it would have, much less that it could help intervene with life-saving care, according to Lori Pearlmutter, Quality Manager for North Country HealthCare. Today, receiving Alerts in the right place at the right time has become an essential tool for care managers at North Country HealthCare, Pearlmutter said.
Founded by a small group of doctors in 1991 as the Flagstaff Free Clinic, the clinic became a state and federally funded community health center in 1996 and is the primary health care center serving 14 communities across northern Arizona. North Country provides a range of health services including primary care, obstetrics and gynecology, pediatrics and behavioral health. Other services offered at multiple clinics include dental, physical therapy and community health programs.
In addition, the center provides support for patients with chronic disease or conditions such as diabetes and offers a number of community health programs aimed at promoting good health and well-being.
North Country HealthCare faces a challenge simply by the size of the geographic area that it covers, serving communities from Lake Havasu in the west to Springerville in the east, and from Payson in the south to the Grand Canyon in the north. Care managers are assigned to the clinics in each of the 14 communities that are served. These care managers coordinate an integrated team that works with high-needs patients with complex or multiple chronic conditions, such as diabetes, or behavioral health issues. They also work with patients with social determinants challenges that affect their health or patients who use hospital and hospital emergency department for care that could be delivered in a primary care setting. Through care managers, patients receive health coaching to make sure they attend appointments and receive support with any necessary transitions from the hospital.
When North Country HealthCare was set up to receive Alerts, patient panels were uploaded according to the clinics where patients receive care so that care managers receive Alerts for their assigned patients. Alerts are received at 8:00 a.m. daily regarding any discharges that have occurred within the past 24 hours, and care managers ensure that clinic providers have the latest information to see which patients are complex or have a higher risk for readmission, so they can be seen first. Pearlmutter says that the Alerts are typically used as a trigger to start a series of follow ups that make provider-patient time more valuable, and this enhanced transition of care ensures that once a patient leaves the hospital, they are ready to resume care at their primary care facility. She says that Health Current (Arizona’s health information exchange – HIE), has been invaluable with these transitions back to their primary care provider, adding that this is a risky time for patients with multiple problems that could lead to a hospital readmission or further medical problems.
Alerts delivered “in the right place at the right time” not only assist in helping patients avoid readmission, they can even lead to life-saving care, Pearlmutter said. For one patient, an Alert may have saved her life. After receiving an alert about her patient being discharged from the hospital, a care manager quickly realized that the patient had cardiac issues with aspiration that had led to aspiration pneumonia. The Alert allowed the care manager to be involved earlier and to follow up with a referral to a cardiologist.
Pearlmutter has seen the Alerts from Health Current improve the ability of North Country care managers to serve their patients, and she refers to their enhanced system of care as “the perfect example of technology and the human touch.”
“The HIE is such a beneficial system that has helped our team receive the most efficient information that we have ever seen,” she said. “From the Alerts, to the follow-ups, all of the data has become more valuable and allows us to provide better care. We are so happy to be connected to Health Current and look forward to all of their accomplishments to come!’