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Long-Term Care


Long-term care (LTC) patients commonly have complex chronic care needs that result in frequent transitions among their homes, acute, post-acute, and LTC settings. When these transitions of care occur, seamless care coordination and continuity of care practices become even more important for providers to achieve in their patient interactions. Critical to this effort are HealthInfoNet’s trusted and reliable Health Information Exchange (HIE) services.

Top Use Cases & Interventions

Evaluate Referrals and Preadmissions

  • Assess care summaries received from primary care providers and hospitalists to inform and evaluate care plans prior to admission

  • Review previous hospital admissions, ED reports, allergy lists, office visit notes, laboratory work and radiology reports, immunizations, active problems, and chronic conditions from various sources

  • Enhance patient confidence and satisfaction by engendering greater collaboration with referring providers

Conduct Medication Reconciliation

  • Confirm correct medication lists during transitions of care by reviewing filled/dispensed medications (over last 120 days)

  • Prevent duplication of medications after discharge to avoid overprescribing, eliminating redundancies and extra costs

  • Monitor medications to prevent misuse and risk of harm

  • Identify potentially adverse drug combinations/interactions and/or dosing levels

Enhance Coordinated Care

  • Increase collaboration among primary care, specialty care, subspecialty care, and other care locations to improve the quality and safety of patients’ care interactions and experiences

  • Manage patients’ care transitions, care coordination agreements, and other protocols to support how care teams work together

  • Update care plans based upon a comprehensive review of supporting documentation and materials compiled from multiple providers from unaffiliated locations

Manage Transitions of Care

  • Provide 24x7x365 secure access to patients’ electronic health records in support of care teams’ abilities to engage patients when it matters most

  • Allow care teams to identify and assign active patients to a panel to track and monitor their time-sensitive healthcare activities in real-time over the course of their treating relationship

  • Ensure acute-care discharge care plans are assembled with the following key components: review of medications, identification of necessary follow-up services, and description of relevant equipment needs

Identify Gaps / Overuse of Care

  • Ensure that duplicate laboratory tests and/or radiology reports are not ordered by reviewing patients’ comprehensive electronic health records

  • Advocate for patients when additional care is needed from another provider or specialist

  • Look for gaps in care to ensure activities are aligned across various healthcare settings

  • Reduce the need for unnecessary documentation for reimbursement purposes

Support Performance Measurement

  • Supports various performance reporting initiatives (e.g., ACO, CMS, MIPS, NCQA, etc.) by providing access to a centralized and comprehensive clinical data repository to fill in data gaps and longitudinal information

  • Assists with the completion of Minimum Data Set (MDS) sheets, including active diagnoses, pain assessments, fall histories, medications, immunizations, and procedures information

  • Tracks health outcomes and equity based on both clinical and community activities and determinants of health and wellbeing

Participant Testimonial

“I utilize HealthInfoNet is just about everything I do. The real-time access to our patients’ medical information facilitates the way we deliver care better than ever before. The ‘hurry-up-and-wait’ scenario to search for and track down records via fax or telephone is no longer necessary. It’s a wonderful asset.”

– Michelle Gagnon, CNP, Nurse Practitioner, Genesis Physician Services

Additional Case Study Resources



Last Updated



How HealthInfoNet Can Help Long-Term Care Providers In Their Clinical Workflows


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Using HealthInfoNet to Support Long-Term Care Use Cases & Interventions


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Using HealthInfoNet to Support Long-Term Care Use Cases & Interventions


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Other Relevant Training/Education Resources

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