Healthlink Advisors team analyzes practice workflows — as well as team members roles and skill sets — to develop IT enablement solutions that promote enhanced care coordination, quality, and efficiency

In primary care practices, technology can enhance efficiency, optimize care coordination, and improve quality measures. But to maximize the benefits of technology, it’s critical for practices to develop a comprehensive IT strategy that integrates seamlessly with practice workflows, EHR software and team members skill sets.

“One of the first things primary care practices need to look at is how their technology facilitates communication across the healthcare continuum, from primary care to acute care to post-acute care,” said Yolanda G. Smith, DNP, RN, MSN, Chief Clinical Officer at Healthlink Advisors. “IT enablement of electronic handoffs can enhance primary care workflows and streamline transitions of care.”

For a patient who needs a follow-up appointment with their primary care physician (PCP) after discharge from the emergency department (ED) or hospital, the EHR can be configured to send a notification to a case manager, care coordinator or PCP’s office. Upon receiving the notification, the PCP, case manager or care coordinator can make a follow-up call to schedule the patient, ideally within 24-48 hours of discharge.

In some cases, EHR systems may be configured to prompt hospital or ED team members to schedule a PCP appointment for the patient before discharge.

Connecting Patients with Holistic, Longitudinal Care

When the patient returns to the primary care physician for their follow-up appointment, the team can utilize the EHR view notes and reports from the hospital or ED interaction, perform medication reconciliation and more — ensuring the patient receives consistent care across the health system.

“The ED or hospital team is looking at treating immediate problems to stabilize a patient,” said Dr. Smith. “while PCP’s provide holistic care by looking longitudinally at all areas of the patient’s health — and with proper use of technology, the PCP can close gaps and promote preventive care.”

Technology can also be utilized to connect patients to community resources that address social determinants of health — such as food or housing insecurity, health insurance needs, unemployment, transportation, and other barriers to receiving care.

“There are software programs that integrate with the EHR and enable providers, care coordinators and case managers to generate a list of community-based organizations within a certain zip code,” said Dr. Smith. “Providers and care teams can coordinate with those organizations and share contact information to patients, make direct referrals, or assist the patient in reaching out.”

According to Dr. Smith, seamless care transitions combined with connections to community-based organizations can lead to better outcomes and reduced readmissions, which improves quality scores for the entire health system.

Educating Clients on Primary Care IT Strategy

When working with health systems on IT strategies incorporating primary care providers, Dr.Smith said it’s important to “connect the dots” between providers with various care roles. The Healthlink Advisors team looks at existing processes from end-to-end to determine the key players, their responsibilities and identify any areas of opportunity.

“It’s important to make sure all involved team members are aware of their roles and how technology can be used to complement them. We also work to ensure team members have the right skill sets and are working to the highest degree of their licensure,” said Dr. Smith. “In an environment where there are shortages of clinical workers, we look at how technology combined with training can be used to fulfill needs for services — such as training team members on when virtual visits can be utilized to reduce the impact of staffing challenges and high patient demand.”

Dr. Smith and her team also work with health systems to identify patient populations who would benefit most from more streamlined care through data analysis. The team starts by deep diving into issues surrounding patient care for a particular group, such as patients with heart failure, and develops pilot programs to meet their healthcare needs.

“We look at things like medication usage, gaps in care, lab and diagnostic tests, social determinants of health, health literacy and more,” said Dr. Smith.

From there, the team creates a plan consisting of operational and technology strategies that align with patient needs and develops a phased implementation plan. The team also identifies metrics that can be used to assess the plan’s success and ensures there is an appointed team member responsible for the ongoing tracking and reporting of them.

But perhaps one of the most important things the Healthlink Advisors team stresses with primary care clients is that technology is only as good as the workflows and the team that is using it.

“We take a ‘workflow-first’ approach, because we know that following best practices for workflow —and configuring technology based on that — delivers the best results,” said Dr. Smith.

Yolanda G. Dr. Smith, DNP, RN, MSN, is Chief Clinical Officer at Healthlink Advisors, a healthcare consulting firm committed to improving clinical innovation, business systems and healthcare IT strategy, delivery, and operations. Our team has extensive experience developing IT solutions to support all aspects of primary care practice operations. To learn about how we can assist your organization, contact us at (888) 412-8686 or info@healthlinkadvisors.com.