Developing Advanced Clinical Pathways for High-Risk Disease Across Your Post-Acute Network

After hospitalization for injury or illness, four out of ten Medicare patients are discharged to post-acute care (PAC). Unfortunately, up to 25% of them, particularly those with chronic illness disease, are readmitted to acute care within 30 days. These conditions are costly with cancer, heart disease, diabetes, obesity, and kidney disease driving 75% of healthcare spending. Two of these chronic conditions top the Agency for Healthcare Research and Quality’s list of the leading causes of readmissions – heart failure and diabetes. Infection, COPD, and psychotic disorders round out the top five.

These findings demonstrate the critical importance of developing clinical pathways between acute and post-acute providers for chronic disease management and prevention of high-risk readmissions. As hospitals and ACOs try to manage patient outcomes across the network, adopting a standard of care on both the medical and functional sides is crucial. This session focuses on how defining standardized care strategies and leveraging live data within the EHR can identify and prioritize high-risk patients in the post-acute setting, lower avoidable readmissions, achieve better patient outcomes, and reduce cost of care.

Learning Objectives

• Describe the importance of standardizing clinical care between acute care and PAC partners to define clinical pathways with priority interventions for different case types
• Identify key staff activities and processes based on evidence-based practice for a specific group of patients with a predictable clinical course
• Explain the four components of comprehensive readmission risk scoring: clinical alerts, length of stay, readmission history, and active diagnoses/co-morbidities

Speaker: Phyllis Wojtusik, Executive Vice President of Health System Solutions, Real Time Medical Systems

This presentation is hosted by The Hospital and Health System Association of Pennsylvania (HAP) and HAPevolve.