CAST has updated its Shared Care Planning and Coordination Online Tool with updated vendor information for 19 products and published a new case study. “Improving Care Coordination and Data Sharing with Acute Care and Payers” illustrates how integration technology can help a provider reduce gaps in care and remain a preferred provider to a health system. CAST Supporter Netsmart and LeadingAge Provider Member Landis Communities partnered on this successful project.
LeadingAge CAST produces and publishes a comprehensive portfolio of hands-on resources that help providers understand, plan for, select, implement, and adopt the appropriate technology while advocating for innovative care models. The Shared Care Planning and Coordination portfolio includes the CAST Shared Care Planning and Coordination for LTPAC Primer and Provider Selection Guide and companion Interactive GuideOnline Selection Tool, Selection Matrix, and Provider Case Studies.


Landis Communities is a five-star, full service, live-at-home facility in Lititz, PA. It offers a 114-acre Life Plan Community, with 825 care recipients and 550 employees. Landis Communities serves Medicare beneficiaries with multiple chronic conditions who may see up to 16 physicians per year. Without technology,

  • Important care information was missing 78% of the time.
  • Three out of 10 tests were reordered because results could not be found.
  • Paper patient charts could not be found on 30% of visits. 

Their findings supported the statistic that 86% of mistakes made in the healthcare industry are administrative.
Team members at Landis Communities knew they needed integration to prevent gaps in care and lower their risk. To reduce those gaps in care, report outcomes, and remain a preferred provider to their local health system, Landis needed to implement a technology strategy. Yet cross-vendor exchange was complex and expensive. 


By implementing Netsmart’s CareConnect for all care settings in its Life Plan Community, Landis Communities aims to stay in the Preferred Provider Network (PPN) with its primary referral source and expand the same strategy to other health system and referral partners in the community.
Landis Communities adopted integration technology that simplified communications with the broader healthcare community, including the ability to connect with multiple EHRs through a single platform and to adopt standards to connect non-acute providers to each other and to their partners. The new technology supports consent management, enables providers to share patient information securely, and supports the existing clinical workflow. 


Outcomes include the following:

  • Improved care coordination and data sharing ability through bilateral data sharing, direct secure messaging, Continuity of Care Document/Continuity of Care Document Architecture (CCD/CCDA) consumption, and electronic transitions of care and referrals with hospitals, health systems, and primary care networks.
  • Improved care transitions and reduced gaps in care.
  • Improved quality of care and outcomes, including improved medication reconciliation and improved care plan transitions with the patient, with no need to search for paper record. Landis Communities also experienced fewer duplicative tests and administrative errors. 

The Netsmart CareConnect Inbox’s efficiencies offset the solution’s total cost. These include connecting Landis Communities to its Accountable Care Organization's General Epic EHR, communicating bi-directionally, receiving CCDs, and discretely consuming information. Landis Communities is also receiving CCDs from Primary Care Physician offices. 


Advice to organizations pursuing a similar project include ensuring that you have enough resources, training, and time to understand and integrate multiple systems. It’s best to make a plan to progress with your technology implementation, and communicate with your various providers early in the game so that they understand your value as a partner. Avoiding multiple dashboards for various partners can also smooth the process.
Read the full case study.

Interested in Shared Care Planning and Coordination?

Read our article on the upcoming LTPAC Health IT Summit if you are interested in shared care planning and coordination and in

  • Learning about products that support care coordination, 
  • Hearing case studies from providers who used such technologies, or 
  • Seeing some of these products demonstrated. 

Then register today to attend the Summit, which will take place June 24-26, 2018, at the Washington Hilton Hotel in Washington, DC.

Read the full case study.