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Thursday, September 19, 2019  Spokane, Washington  Est. May 19, 1883
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Software program helped keep tabs on vulnerable patients

Brittany Pring, a care transitions coach with Aging and Long Term Care of Eastern Washington, smiles while making a call to check on a patient’s wellness last month. (TYLER TJOMSLAND
Brittany Pring, a care transitions coach with Aging and Long Term Care of Eastern Washington, smiles while making a call to check on a patient’s wellness last month. (TYLER TJOMSLAND

As smoke and ash darkened the skies this summer as wildfires burned more than 1 million acres across the state, Spokane health workers were able to identify patients with respiratory illnesses within seconds and send help.

The same software was used in November when hurricane-force winds caused record power outages. Aging and Long Term Care of Eastern Washington was able to use the program to locate people on oxygen or other medical-support machines that depend on electricity. As the days without power continued, they also could contact clients who were cold or running low on food.

“If I had to go through all the charts by hand I’d probably still be trying to do it,” said Teresa Michielli, the care services director who oversaw the Bridging Care Across the Inland Northwest program that helped at-risk Medicare patients transition out of the hospital to their homes. The program ended this week.

Care at Hand created and provides the software that Bridging Care used to identify patients who are most at-risk, for instance allowing them to reach out to patients with respiratory illnesses during the wildfires. The focus is to keep patients thriving in their homes and decreasing the need for hospital stays and more expensive medical interventions.

Bridging Care coaches would ask patients discharged from the hospital a short set of survey questions that were entered into the Care at Hand software. That information is easily searchable and can provide community health workers specific reports that can help identify potential problems and get solutions, such as getting the patient in contact with a nurse before a patient needs to go back to the hospital.

During the wildfires and windstorm, Michielli said, the information was invaluable.

“Almost every person we contacted was really grateful to have someone check in on them,” she said.

The aging services provider already uses similar databases created in-house but nothing as comprehensive or complete as Care at Hand.

Andrey Ostrovsky, a Washington, D.C., pediatrician and social entrepreneur who co-founded Care at Hand, said home- and community-based services are the key to improving patient health. He believes the community providers should work with hospitals, and together they can reduce hospital admissions and readmissions. In the end, it would reduce medical costs.

“ALTCEW is a very progressive provider,” Ostrovsky said, because it is already working with hospitals.

Now that the federal pilot has ended, Ostrovsky said it’s unclear if ALTCEW will find another way to use Care at Hands services but it could help it negotiate other transition care programs with area hospitals.

He advocates for hospitals to trust community providers more. He also thinks a national committee to measure the quality of services provided by community and home health providers, just as is done for hospitals and medical providers, would be useful. Yet, he said, progress is slow.

“We need to help people thrive in the community,” he said.

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