Despite widespread adoption of electronic health records at hospitals and (to a lesser extent) post-acute care facilities, care coordination and outcomes monitoring among both types of providers are still often a big challenge.
For example, patients discharged to skilled nursing facilities and other PAC sites experience a 22.8% readmission rate nationwide, compared with 13.9% for all discharges.
THE CHALLENGE
TriHealth, a four-hospital not-for-profit health system and accountable care organization in Ohio with 140 care sites and a network of more than 200 skilled nursing facilities, sought to reduce those readmissions and help patients safely return to their homes sooner.
But the health system had limited awareness of its patients’ health and status at PAC facilities due to antiquated monitoring methods that typically involved sending faxes and making phone calls.
Once patients were discharged to an SNF from one of the hospitals, visibility into their health status and trajectory was limited and inconsistent, significantly reducing staff’s ability to intervene promptly, said Lori Baker, director of population healthcare management and post-acute network at TriHealth.
“This was primarily due to the tedious administrative steps and convoluted processes required to obtain clinical updates, typically through phone calls and even faxes,” she explained. “As such, our readmission rate from SNFs reached 25%. Our patients’ length of stay at SNFs was 25 days on average.
“As an ACO, we knew this post-acute care transition and coordination process was not a sustainable model if TriHealth was going to succeed in any value-based care payment program in the future,” she added.
PROPOSAL
The ACO leadership team went to Baker with a goal to reduce the readmission rate from 25% to 20% and, likewise, the LOS from 25 to 20 days on average, which, at the time, Baker thought was unrealistic.
“To accomplish that, we needed to develop a new post-acute care collaboration process where our care managers could spend far less time searching for and updating information in our electronic health record and more time collaborating with clinicians in SNFs to reduce a patient’s risk of readmission,” she said.
“What our post-acute care collaboration system needed to do was offer visibility into what we used to call the ‘black hole’ of data,” she added. “This meant we would discharge patients to SNFs with extensive information about their hospital stays and a care plan, but it was pretty difficult to get any information from the facilities. Part of the problem was the need for a platform with easy access to patient information during the SNF stay.”
The post-acute care management system would eliminate the need for many phone calls, checking the fax machine and waiting to gather updates. It would also alleviate the need for care managers to manually collect and enter information into a patient’s chart. That benefit alone would offer enormous time savings and real-time information.
“Perhaps most important, the system would need to offer our care managers, who monitor patients in the SNFs and our providers in outpatient clinics, actionable information, not just general patient status,” Baker explained.
“With a predictive view of patient risk level and access to in-depth clinical notes, care managers could more efficiently triage patients across the various post-acute facilities and prioritize care collaboration with clinicians in SNFs with the highest-risk patients.”
MEETING THE CHALLENGE
a post-acute care management platform that offered a simple, automated way to exchange clinical insights between their care management teams and post-acute facilities
TriHealth implemented across 45 facilities a post-acute care management platform called PAC Management from health IT vendor PointClickCare. The platform is integrated into TriHealth’s Epic EHR system and provides care managers with a complete view of a patient’s care history, status and trajectory.
“This is possible because the platform connects to the largest healthcare network in North America that includes all the SNFs in our network,” said Baker.
“Care managers or primary care physicians in outpatient clinics can log in to the system daily to view real-time clinical insights, providing comprehensive visibility into admissions, discharges, status reports, LOS, therapy documentation and individual patient clinical data.
“Along with this data, our clinicians can view readmission risk indicators and analysis from the platform’s predictive return to hospital algorithm,” she continued. “The machine learning algorithm helps identify patients with a rising risk of rehospitalization and the potential factors contributing to the increasing acuity.”
This enables care managers to quickly prioritize patients who require attention and helps streamline clinical management, she added. The new process enhances patient care while boosting CMS quality measures and overall performance, driving improvements across the network, she said.
RESULTS
“Even though I believed a 20% readmission rate was a longshot, since the implementation of our post-acute care management platform, the readmission rate from our SNF network is down to only 18%, a 28% decrease,” Baker reported. “We also reduced the average LOS from 25 to 18 days, a 28% decrease.
“Further, we calculated our estimated cost savings compared with well-managed ACO benchmarks and determined that, thanks to these improvements, we are likely to save at least $8 million annually,” she continued. “I do not believe any of it would have been possible without the technology we now have available.”
Moreover, although not having hard results, the working experience of care managers responsible for monitoring patients in SNFs has significantly improved because of the reduction in manual data management activities, she added. Families also are grateful that TriHealth can provide them with data about SNFs because they are typically unaware of all the facilities in their area, she said.
ADVICE FOR OTHERS
Baker advises health systems working with large networks of SNFs and other post-acute care facilities that any technology they implement must offer real-time data from these facilities and automate as much manual data management as possible.
“By removing the non-clinical duties from post-acute care monitoring, our highly skilled and experienced care managers can practice at the top of their licenses, identifying which patients require interventions, developing the most effective care plans, and more efficiently collaborating with the clinicians in the facilities,” she said.
“Likewise, the technology health systems select should offer more than just data, but a truly holistic picture of the patient,” she concluded. “Data alone may or may not be meaningful, so the technology should help put the pieces together. By offering clinicians insight into which patients appear to be decompensating or more likely to be readmitted, higher-risk, higher-need patients can receive interventions first.”
Follow Bill’s HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
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