NAACOS Breakfast Session: Developing Advanced Clinical Pathways for High-Risk Disease Across Your Post-Acute Network

As the baby boomer population ages into retirement, it is estimated that Medicare enrollment will catapult to 80 million beneficiaries by 2040. This generation is not only living longer, but they also present more complex healthcare needs. According to the National Council on Aging, 80% of older adults have one chronic illness while nearly 70% have two or more – meaning more people than ever will rely on our nation’s healthcare delivery system.

Drill down further and you’ll see that 40% of Medicare patients hospitalized for injury or illness are discharged to post-acute care (PAC). Unfortunately, up to 25% of them, particularly those with chronic diseases, are readmitted to acute care within 30 days. These conditions are costly with cancer, heart disease, diabetes, obesity, COPD, and kidney disease driving 75% of healthcare spending and readmissions.

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 PAC EHR data can identify and prioritize high-risk patients in the post-acute setting, lower avoidable readmissions, achieve better patient outcomes, and reduce total cost of care.

Learning Objectives

• Establish 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
• Demonstrate the four components of comprehensive readmission risk scoring: clinical alerts, length of stay, readmission history, and active diagnoses/co-morbidities

Presenter: Phyllis Wojtusik, RN, Executive Vice President, Real Time Medical Systems.

This session is part of the NAACOS 2022 Spring Conference.