“We previously looked at different metrics, but stopped as they were too hard to track and were not an accurate representation of the outcomes.”

Background

PACE of the Southern Piedmont located in Charlotte, North Carolina serves local seniors in Cabarrus, Mecklenburg, Union, and Stanly counties. The Program of All-Inclusive Care (PACE), which opened in 2013, provides interdisciplinary services to clinically complex participants, allowing them to remain in their homes while receiving comprehensive and quality healthcare services.

The Challenge

While PACE of the Southern Piedmont worked diligently to establish a data-driven Falls Committee, their access to actionable data was fragmented and manual. This challenge led to 2+ hour meetings, manual spreadsheet auditing, and countless staff hours spent to prepare and share relevant information.

The traditional process included significant manual lifts to track and aggregate data from their electronic health record (EHR), limiting efficient, comprehensive, and preventative discussions.

The Solution

In fall of 2022, PACE of the Southern Piedmont began a falls performance improvement initiative and partnered with Intus Care to become more preventative and efficient. During this initiative, Intus Care Falls Analytics were implemented as a tool to empower the process by eliminating manual data aggregation, visualizing relevant risk factors, and automatically tracking performance outcomes.

Falls “play an important role in preventing hospitalizations and inpatient rehabilitation services,” said Daniels.

PACE of the Southern Piedmont reformatted its monthly Falls Committee meeting around the Intus Care platform.

“Based on the information we get from Intus Care, we have redeveloped our process to look at the risk acuity. That was a light bulb moment for us as a team to say, ‘we’re talking about what we are doing to address these falls, but we’re not talking about how we got there,’” said Daniels. “We are now adding risk into the conversation. What did we see, what had changed, or what are the events that got us to this point
where the person is falling? What are the risk factors?”

Participant Falls Analytics Example (Deidentified)

Intus Care’s software also allows the organization to cross reference common conditions amongst frequent falls to identify root cause analysis and drive change in targeted populations. Through their Stoplight Program, PACE of the Southern Piedmont assigns stoplight-colored lanyards to participants based on fall risk. Red is for high-risk fall participants, yellow for moderate-risk participants, and green for low-risk participants. “It’s a visual representation so staff can help make sure everyone is safe,” Daniels said.

The reformatted Falls Program is mitigating manual data aggregation and facilitating meaningful interventions through automatic insights, correlations, and risk factors, all with the goal of improving the participant’s quality of life.

Impact

The organization has realized significant improvements since beginning the performance improvement plan and integration of Intus Care software. Following the launch of their Falls Improvement Initiative and the Intus Care partnership in October 2022, the organization saw their October fall rate of 17.1 Falls per 100MM drop to 11.4 Falls per 100MM by the end of April 2023.

“Incorporating the risk factors has been a big step for us… To me, that’s one of the most important pieces of what we do.” Daniels added, “The participants’ quality of life is a true measure of success. We aim to see participants staying out of the hospital, staying in their home safely, and thriving there.”

Let’s build something better, together

Whether you’re launching a PACE program or switching from another EMR, our team is ready to support a smooth, confident transition to CareHub. Ready to learn more about how we can partner for success?