As a physician assistant and current vice president of TruHealth, which serves as the clinical team for national I-SNP and Medicare Advantage operator American Health Plans, Bridget Grover’s day-to-day experience is driven by clinical needs among the aging population.
In this Clinical Dashboard interview, Grover shares her insights based on being a partner to hundreds of skilled nursing facilities through TruHealth, including the most important data, access and metrics health care providers — and payers — need to know.
What are the three most important data points that you would want to see each day on your ideal clinical dashboard and why?
TruHealth utilizes a clinical dashboard daily because we realize that data is critical for delivering high quality healthcare, making informed decisions, advancing medical knowledge and improving patient outcomes.
Our current dashboards look at overall transitions in care as well as specific associated diagnoses. This information allows us to understand diagnosis trends and tailor our educational activity not only to our TruHealth team, but also skilled facility staff teams, for best practices with treating in place.
Our clinicians also utilize a dashboard that takes information from the member’s overall health risk assessment to provide a frailty scale. This information allows our TruHealth staff to assess a member’s risk of complications such as falls, hospitalizations and mortality. This data gives our staff the ability to provide timely interventions and personalized care.
How would the ideal clinical dashboard drive patient care decisions?
The right data can really help drive our staff to concentrate on areas that will provide improved outcomes. For example, when looking at risk along with diagnosis, we know that a plan member who has already been hospitalized three times in the previous six months will need more one-on-one time spent with that individual as well as education for all appropriate stakeholders. Often having increased conversations about disease trajectory with families promotes more coordinated and patient-centered care.
Having access to a robust clinical dashboard has been instrumental to our ability to achieve improved patient outcomes, better education and guidance regarding healthcare goals. This has resulted in a reduction in unnecessary re-hospitalizations among our American Health Plans members by approximately 40%, encompassing both emergency room visits and inpatient admissions.
How would the ideal clinical dashboard help optimize reimbursement?
We also utilize an EMR that provides us with accurate information on the diagnosis of our patients. Accurate coding ensures that we are reimbursed appropriately for the care we deliver. Discrepancies can lead to over or underpayment.
How can the clinical dashboard improve staffing efficiency?
Our unique model of care provides a very high-touch clinician-to-member ratio, meaning we strive to be present in the facilities we serve frequently. Due to this, often there is travel involved. We can utilize a productivity tracker that includes travel as well as membership location to allow for the most efficient staffing but also to provide that excellent in-person care at the bedside.
How would you like to see the clinical dashboard integrated with predictive analytics tools?
We are working with our current EMR called Patient Pattern, part of the PointClickCare platform, which integrates with skilled facility EMR systems. This integration will flow over updates on transfers of care, and changes in medications, and in time flag our staff with vital changes, just to name a few. I believe this technology will revolutionize how we will provide care in the future. Quicker, more timely information on changes in patient condition allows for improved care of our members and will decrease unnecessary hospitalizations. TruHealth is constantly looking at how it can leverage technology to provide the best outcomes for our patients and our partners.
Besides yourself, what are the most important roles in your organization to also have access to the clinical dashboard?
At TruHealth, we work with all our staff to ensure they know the important data metrics as this is a lever of driving care. Everyone from our directors, nurse practitioners and RN/CM to our CNAs know the metrics of their members and why that is important. We also use the data to help educate our partner homes, and so we have improved collaboration to enhance our efforts together. This collaboration is unique to our provider owned I-SNP because there is a deeper understanding and desire to provide the best results.
What would you do to improve the collection of patient health data?
Currently we are working to move all our data to one dashboard for quicker retrieval. We have several dashboards that will all be integrated into one large dashboard in the coming months. This will allow our team to have even quicker and more efficient information at their fingertips. This data easily flows into charts for an improved visual to interpret and understand quickly.