Promoting Quality and Care Coordination: An Interview with Edgewood Place Skilled Nursing Facility

Promoting Quality and Coordination Across the Care Continuum: An Interview with Edgewood Place Skilled Nursing Facility on Technology in the Post-Acute Care Environment

In today’s increasingly connected world, it is becoming a standard industry practice for hospitals to interact with patients using technology. With CMS reimbursements now tied to patient satisfaction and quality measures, hospital leaders understand the importance of using technology to capitalize on payment reform. More recently, post-acute care (PAC) providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs) have turned to technology to comply with similar regulations.

To promote care coordination across the continuum, CMS will soon require PAC providers to standardize and report on quality, outcomes, and satisfaction. This increased transparency pushes PAC providers to improve the experiences of patients and residents, optimize care services, and reduce readmissions. Using hospitals as a model for success, it is clear that technology will be a key factor in this changing PAC landscape.

Recognizing this shift, Edgewood Place at the Village at Brookwood, a skilled nursing facility part of the Cone Health System in central North Carolina, has turned to innovative technology to improve residents’ experiences and outcomes. Edgewood recently partnered with CipherHealth to implement CipherOutreach, a post-discharge follow-up calling platform, and Echo, a digital tool to record personalized discharge instructions. This collaboration demonstrates Edgewood’s mission to keep residents healthy and happy long after they leave the facility.

Steve Swanson and Teresa Pennington, Administrator and Administrative Office Manager at Edgewood Place, spoke with CipherHealth about how they are strategically implementing technology to improve the care experience and prepare for payment reform.

Interview with Steve Swanson and Teresa Pennington

CH:  As you were making the decision to implement CipherOutreach for your follow-up calling program, what were the primary challenges that you were trying to address? What specific goals did your organization have when partnering with CipherHealth?  

Edgewood:  Our goal when implementing CipherOutreach was to receive feedback from residents about our care services and quality in a direct way. We partnered with CipherHealth not only to receive this important feedback, but also to have a better, more streamlined way to address any issues that residents may have related to their care. This program quickly became an essential component in providing high-quality care services.

CH:  What have been the residents’ reactions to the automated calls?

Edgewood:  The residents have been extremely responsive to the follow-up program. Through the reports we receive from CipherHealth, we see that the majority of our residents complete the entire CipherOutreach call, and when callback is required, tend to be very honest with our staff. This allows us to address issues before they lead to adverse events, such as hospital readmissions. This proactive issue resolution also helps increase resident satisfaction and boost referrals.

CH:  Was implementation of the calling system difficult?

Edgewood:  From the beginning, the calling program was very user friendly and easy to implement. Should we experience any difficulties, the Cipher team is always available and eager to lend support to ensure that we are comfortable with the technology.

CH:  What have you learned about your residents through the CipherOutreach and Echo programs?

Edgewood:  We have learned that many residents do not fully understand their discharge instructions at the point of discharge, but may not speak up at that time. Despite this initial apprehension, residents tend to acknowledge that they need help on the CipherOutreach calls. Our staff is automatically notified of these issues or questions, and we can intervene prior to the residents making a medication mistake, improperly managing their care, or returning to the hospital.

CH:  What are some of the successes that you’ve seen since implementing CipherOutreach and Echo?

Edgewood:  By spotting trends in residents’ behavior and issues reported, we have been able to address several challenges that are typical of SNF residents post-discharge, for example, helping them obtain DME, Medications, and O2. CipherOutreach and Echo have also allowed us to promptly answer medication and therapy questions to prevent mistakes that could lead to hospitalizations.

CH:  Can you speak to the value that you see in Echo, the digital discharge instruction recording tool, specifically?

Edgewood:  With the Echo program, residents have the option to go back and listen to discharge instructions as many times as they would like at their convenience. This helps ensure that residents understand their care plans and comply properly with instructions. We’ve seen that the residents who listen to their Echoes have required fewer manual callbacks or interventions from staff.

CH:  What is the role of innovative technology in SNFs, as players in the industry work to position themselves as a value-base partners to their referral sources?

Edgewood:  Innovative technology is the most effective way to consistently receive meaningful feedback and drive improvements. We see the direction that medicine is moving in, and we believe that care does not end when a patient or resident walks out your door. We aim to offer high-quality care from the beginning of a resident’s experience to the end. Care must be coordinated at all levels, from hospital – to SNF- to Home Health – to outpatient – to independence, and on. We must work to prevent readmissions and additional expenditures to the referral sources, insurances, and the patients.

Key Takeaway

As highlighted by leaders at Edgewood Place, care extends far beyond the point of SNF discharge. Arguably, the window immediately after a patient or resident returns home or transitions to a lower acuity care setting is the most important time for providers to reach out. Having a robust discharge process including patient or resident follow up helps to prevent avoidable complications and hospitalizations, and creates a positive, lasting impression of the care experience. For Edgewood, incorporating CipherOutreach and Echo has allowed the organization to better understand its residents and make informed changes to improve quality of care and outcomes.

To learn how your organization can partner with CipherHealth to improve quality of care and outcomes, and prepare for payment reform, contact us today.


Ranked as the “Best Overall Patient Engagement Company” in MedTech's Breakthrough Awards for 2020, and the top-performing vendor for patient outreach and digital rounding by KLAS in 2019, CipherHealth is a proven technology partner committed to enhancing communication and coordination throughout the patient journey. CipherHealth’s suite of patient engagement software empowers healthcare organizations to foster meaningful connections to ensure the best possible outcomes for staff members, patients, and their loved ones.