Problem
Kindred Transitional Care and Rehabilitation provides continued care to a broad range of patients with a diverse set of needs. Often, these patients have complex health issues but are sent to the facility from an inpatient hospital stay with minimal information included in their chart. Kindred looked to CareWeb to help fill in gaps about their patients to ensure they continue moving forward with their recovery.
Solution
CareWeb has become part of Kindred’s admissions process, providing important information on the patient’s medical history, medications and previous clinical testing, like imaging reports and lab draws. This information enables Kindred to know what has been going on with the patient proactively and implement their care plan from the first moments of arrival.

The information available via CareWeb includes conditions for
which the patient has been seen, and what specialists have been involved in the patient's ongoing care. This knowledge helps the staff set a discharge plan for these patients, which can include making follow-
up appointments for the patient before they even leave the facility. Kindred can share their discharge plan electronically via CareWeb to these specialists for better care coordination.

During their stay at Kindred, if a patient goes to the hospital, CareWeb is used as part of their root cause analysis to see if the staff could have done anything differently to avoid an inpatient visit.
Keywords
CareWeb, care management, care coordination, long-term post acute care, LTPAC, elderly, high-risk, care coordination, long-term care facility, nursing facility, transitional care, transitions of care, post-acute care
Identifier
Ashley Lory
Kindred Transitional Care and Rehabilitation
Director of Nursing Services
Clinical Setting: Post-Acute Care
Benefits
  • Supports better communication between patients and their providers
  • Saves staff time and frustration searching for clinical information
  • Helps speed patient intake
  • Supports root cause analysis and process improvements
Quotes

CareWeb is especially helpful for us as we receive new patients and need to know more about their history. Often, our patients can’t recall the names of their physicians or provide a complete picture of their medical history.

I can’t imagine not having CareWeb at our facility.

Through CareWeb, we are able to view the patient’s discharge notes right away, so we can request their medications at, or prior to, arrival. This is a huge deal for patients, because often there is a lag time between their arrival and when their full discharge summary is completed from the sending facility.

If a patient returns to the hospital during their stay with us, we use CareWeb in a root cause analysis to help determine if we could have done anything differently to avoid this situation.

Case Study

Situation:
The Social Security Administration provides 70,000 disability determinations each year for Indiana.  CareWeb is used to help to determine disability eligibility efficiently and more accurately.

Benefits:
According to SSA, this saves hospitals $2 million from removing claimants from uncompensated care.

What it Means:
Approved claimants can get back on their feet faster.  Provides better and more efficient use of taxpayer resources.