During a virtual featured session sponsored by Real Time Medical Systems as part of Becker’s Hospital Review 11th Annual Meeting, Di Smalley, Health System Advisor to Real Time and Phyllis Wojtusik, Executive Vice President of Health System Solutions with Real Time outlined how interventional analytics improves care and lowers costs for post-acute care networks.
Five insights from the session:
- Live data leads to more integrated networks and higher quality care. Health systems are familiar with claims data. Unfortunately, this information is retrospective and often three to six months old. Live data is more powerful, since it shows what’s happening moment to moment with patients in a post-acute care setting. Live data includes current clinical information like vital signs, orders, labs, clinical alerts, patient risk stratification current length-of-stay, and other trends. “Live data helps health systems communicate more effectively with post-acute providers and work collaboratively to prevent poor outcomes,” Ms. Wojtusik said.
- Health systems and post-acute care providers must work together to prevent readmissions and manage length of stay. Health systems still have a responsibility to oversee and manage patient care, even after people leave their facilities. When health systems bring clinical resources to bear in post-acute settings, it’s possible to monitor care plans and make changes at the individual and system levels that can prevent readmissions and manage length of stay. Ms. Wojtusik observed, “Length of stay in post-acute care equals cost per case. Communicating honestly and openly across the healthcare system and post-acute teams just makes sense. When you overcome barriers to care delivery, it really improves outcomes.”
- High-risk patient outcomes improve when health system care managers focus on clinical changes after care transitions. When patients move from higher levels of care to lower ones, their readmission risk rises during the first three days due in part to errors in transitions of care. Care managers can prevent readmissions by looking for clinical changes in skilled nursing facilities’ EHRs. Using telehealth for nights and weekends is another way to prevent readmissions, since post-acute care facilities often send high-risk patients to the emergency department for assessment and testing during non-business hours. Preventing just one readmission equates to $15,000 in savings.
- Standardization and coordination of care translate into a better patient experience. To manage patient outcomes across the network, standardized care is needed on both the acute and post-acute sides. During the session, Ms. Wojtusik shared a real-world example involving a major academic trauma center. The trauma center had been discharging patients to rehab with hemoglobin levels of six or seven. Many of these individuals were readmitted to the hospital due to syncope or hypotension because they weren’t stable enough to handle the stress of rehab. In response, the acute and post-acute care teams came together and changed the care standards. Now patients aren’t discharged to rehab unless their hemoglobin levels are eight or higher.
- Continuous improvement is a sign of strong partnerships across the network. Collaboration between hospitals and PAC networks ensures shared goal setting, standardized care, and implementation of proven best practices—all with the focus of improving patient outcomes, particularly during critical transitions of care. Those best practices can include warm handoffs during care transitions, reporting unblinded data on a monthly basis, assessing average length of stay by case type and analyzing the root cause of readmissions.
To view this session on-demand, click here.
