A recent study found that 20 percent of Medicare patients discharged from the hospital will be readmitted within 30 days due to a lack of transparency around care transitions.
With the number of Americans aged 65 or older projected to reach 83.7 million by 2050, it’s essential that providers address the issue of better managing care coordination to control costs and achieve better outcomes. At Saint Francis Healthcare Partners (SFHCP), an ACO affiliated with the largest Catholic hospital system in New England, we developed a post-acute care transitions program as part of a broader care coordination strategy for our Medicare Shared Savings Program population.
The state of Connecticut has a skilled nursing facilities (SNF) utilization rate that is nearly twice the average national rate, which greatly impacts the total cost of care for our ACO. We found that not only did we have high costs associated with SNF utilization, we also had high SNF average length of stay (ALOS) and readmission rates. To better manage our patients using SNFs, we wanted to create a system that allowed us to appropriately streamline patient care and reduce costs and improve the quality of care for our patients. To achieve the above process, SFHCP instituted a Post-Acute Care Transitions pilot program with the goals of reducing 30-day readmission rates and ALOS. The pilot program—implemented at one high-volume, preferred SNF—consisted of multiple components working in harmony to bring about desired results, including:
• Placing a full-time RN navigator onsite at the SNF
• Collaborating with SNF staff in weekly inter-disciplinary team meetings
• Providing an estimated length of stay (ELOS) guideline for each patient based on the patient’s discharge diagnosis
• Addressing delays with an interdisciplinary care team
• Updating the PCP upon discharge to ensure timely follow-up care
• Engaging home-health agencies
While the initial pilot was a success, we needed to find a tool to help us scale the program. We sought out a real-time care coordination application, PatientPing, to provide us with instant notifications for admissions to SNFs. We believed this would prevent delays in providing an ELOS guideline to our partner SNFs and would assist with identifying SFHC-attributed patients, allowing us to increase collaboration with our preferred network of SNFs. PatientPing’s technology provides us with timely information on patient transitions which allows us to create care plans, follow up with the primary care physicians, complete post-discharge phone calls and medication reconciliation, and connect with home-health services timely. Essentially, it facilitates robust data sharing with all partners around our ACO.
By having this real-time information, we were comfortable expanding our Post-Acute Care Transitions pilot program because the tool enabled us to maximize efficiencies and increase the productivity of each employee. With this expansion, SFHCP created a team of care managers that were responsible for ACO patient movement across the continuum and expanded the program to cover 13 SNFs. Post-Acute Care Managers were alerted in real time to any in-network SNF admission and discharge which helped our post-acute care managers to do the following:
• Provide the SNF team with an estimated LOS on day one so they can begin transition planning early and identify barriers to discharge
• Work directly with the SNFs to build a discharge plan for the patient’s transition home
• Complete Transitional Care Management (TCM) phone calls within 48 hours of discharge to reduce risk of hospital readmission
With the expansion of our program and the adoption of PatientPing technology, SFHCP has accomplished the following:
• Reduced re-hospitalization rate for the identified population within the preferred SNFs by more than 30 percent
• Reduced the ALOS for the identified population within the preferred SNFs by 27 percent
To achieve similar success, here are three ways that providers can make the most of patient data and drive care coordination:
1. Create organizational alignment across all participating facilities: Involving key partners inside and outside of your organization is critical before undertaking a pilot program or large-scale roll out. It’s important to have buy-in from stakeholders across the continuum to maximize results.
2. Establish realistic goals: SFHCP recognized our SNF expenditure and ALOS rates as key drivers to our healthcare costs and then set quantifiable goals to help move the needle. Identifying opportunities for improvement and setting realistic expectations is the foundation for success.
3. Monitor, measure, repeat: Starting an enhanced care coordination program with one facility allowed us to identify areas for improvement, make tweaks and then eventually roll it out to thirteen facilities. The addition of the real-time care coordination tool provides the necessary insights to make this process a reality and drive results.
With the pressure to achieve value-based care goals and the continued rise in aging patient populations, healthcare organizations must proactively equip themselves with the necessary tools to drive value, while ensuring the best patient care.
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