Care Coordination Tools with Cerner EHR Help Children’s National Streamline Discharge


Children with complex conditions need more time, medical care and rehabilitation services to recover after discharge from hospital. However, unique challenges persist in finding appropriate post-acute care beds and care.

The 2014 Pediatric Post-Acute Care Hospital Transitions: An Evaluation of Current Practice study, the first known to detail the frequent use of admission and discharge practices for U.S. pediatric hospitals, found that there is variability in transition practices. As hospitals take a closer look at transitional care strategies to address the value-based care associated with aging adults, children need to be considered.


At the Children’s National Health System in Washington, DC, case managers placing children with special needs have often encountered facilities that are ill-equipped to treat certain conditions and lacking pediatric nurses, beds, or appropriate medical equipment, for example. , power probes and adapters.

Another challenge was to find local subacute care. Case managers spent extraordinary time resolving these issues in addition to printing and faxing documents – medical history, progress notes, discharge summary and more in the electronic patient record – to providers. Follow-up calls were made to ensure reception and if additional information was needed. There followed a relentless wait to see if the patient was accepted.


Two years ago, the healthcare system decided to reconfigure its post-acute care transitions to achieve smooth patient transfers. The institution turned to a more strategic use of technology to eliminate time-consuming administrative activities and find the right facility to support the patient’s healing journey. Children’s National chose the care coordination technology provider Ensocare.


There are many care coordination systems on the market. Besides Ensocare, providers include Allscripts, b.well, Caremerge, Imprivata, MyHealthDirect, PatientPing, pMD and Seremedi. Last month, Microsoft revealed plans to market its own care coordination tools.


Ensocare Transition is care coordination software that enables case managers and discharge planners of the national children’s health system to connect patients and their families with the appropriate discharge resources quickly and efficiently.

Discharge planners use the software for all existing patients who require specialist home resources specific to their condition or who require placement and transition support to subacute and rehabilitative care facilities.

“Previously, our case managers placing children with specialized needs often encountered ill-equipped facilities to treat certain conditions and lacked pediatric nurses, beds or appropriate medical equipment,” said Sabrina Smallwood-Mason, RN, Head Nurse and Payors Reimbursement, Refusals and Appeals Analyst at the National Children’s Health System.

“Another challenge was to find local subacute care,” she added. “The Case Manager has spent an amazing time resolving these issues in addition to printing and faxing documents to vendors.”

Using care coordination software for the past two years, Children’s National is distributing these same materials in 237 personalized referral packages per month to the right matching provider. The packages also include the last three days of hospitalization and patient demographics and insurer information. The healthcare system is also introducing Ensocare to its outpatient case managers to help provide new resources for patients and families.

Ensocare Transition is integrated with the Cerner electronic health record system of the health system.

“If the two systems weren’t compatible, automated discharge planning and smooth post-acute care transitions just wouldn’t work,” Smallwood-Mason explained. “The integration eliminates the need for faxing, repetitive phone calls and other time-consuming office activities.

“Once the discharge planner selects and customizes the appropriate referral placement package for the patient, the employee can then take the next step of selecting the appropriate clinical and service providers that best match the needs. clinical and psychosocial patient ”, she added.

Within seconds, selected patient-specific packet information is transmitted to the appropriate facility and tailored to support the patient’s post-care healing journey.


As mentioned, using the Care Coordination Hospital Discharge Management System, 23 National Child Case Managers can now distribute key documents grouped into 237 personalized referral kits each month to the right provider.

Response time averages 30-40 minutes for 80% of skilled nursing, rehabilitation, home care, and other eligible providers, who are more responsive in helping children transition to care. post-acute care facilities, Smallwood-Mason said.

“Case managers previously filled in referrals sent to providers by faxing printed documents from the electronic record,” she added. “This faxing activity was very time consuming and overwhelming due to the sheer volume of pages per patient.

Also, because faxes were not always transmitted securely, case managers made follow-up phone calls to ensure they were received, she said.

“Today they no longer have to do both tasks and the result is increased productivity,” she said. “The system allows the case manager to see the time and date the referral was opened, and when the provider accepted, reviewed or declined the request. The case manager can communicate by SMS with any provider of the referral. corresponding post-acute care identified as necessary. “

The care coordination software also improves the accuracy of the information, she said.

Children’s National has also achieved significant savings for the department by eliminating paper purchases, overtime and office staff hours, she added.

Although the same clinical information is captured as for any reference, documents such as charitable requests can be obtained for the patient or a family member to complete, along with the financial documentation captured.

On another front, it’s fair to say that prior to using the care coordination software, making a referral was not seamless, Smallwood-Mason said. The software allows the case manager to see what is happening with the referral throughout the process, taking the guesswork out of it, she explained.

“Before software, baseline completion time could be variable, from a few hours to a few days in some cases,” she said. “The need for communication by telephone was essential to verify if the referral had been received, if all the documents necessary for the referral had been received, and also when the services would be provided. This was a problem, as it required the case manager to be available to receive phone calls from providers. “


“I would say to anyone struggling with the administrative inefficiencies inherent in ‘the way we’ve always handled cases’ to consider how much time you can free up by turning to technology solutions,” Smallwood-Mason said. “A lot of case managers think the technology ‘will take their jobs’ or replace them.”

In fact, letting technology handle these things that can be automated gives the case manager more time to spend face to face with patients, she said. This is the reason why most have joined this profession, to help people – standing in front of a fax machine eight hours a day does not help people.

Twitter: @SiwickiHealthIT
Email the author: [email protected]


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