Post-Acute Data Transparency Improves Patient Outcomes & Reduces Cost

As post-acute care (PAC) spend continues to rise and CMS continues to move forward with value-based, risk bearing models of care, it is essential for ACOs, payers and hospital providers to take proactive measures in finding innovative and cost-effective data-driven solutions/strategies to meet the future demands of healthcare. Yet, disparate EHR systems between acute and post-acute providers continue to pose challenges in the ability to access live patient data across care settings to improve both clinical and financial outcomes.

Utilization of an EHR-agnostic platform, which mitigates interoperability issues, can foster seamless implementation of standardized care pathways, improve care transitions, better manage patient outcomes, and ultimately reduce total costs within post-acute networks by reducing readmissions and length of stay. St. Joseph’s Health System (SJHS) implemented such a platform and instituted a PAC nurse navigator (NN) role to manage their value-based patients in PAC. As a result, their MSSP ACO, Mission Health Coordinated Care (MHCC), realized a significant reduction in readmissions from 24 to 15.9 percent and achieved a total cost of care savings of $3.277M in its first two years of implementation. Due to their successful post-acute strategy and programming, the project was scaled to include all patients in value-based contracts.

Learning Objectives

• Describe how post-acute data transparency empowers clinical teams to immediately identify trends and improve network performance and patient outcomes in PAC facilities
• Discuss strategies utilizing live post-acute data to reduce readmissions and minimize length of stay resulting in improved quality performance and total cost of care savings in post-acute populations
• Analyze performance of post-acute providers to implement data-driven standardized care pathways for common chronic conditions in aging/post-acute care populations

Speaker:

• James Giordano, MBA, Executive Director St. Joseph’s Health Partners CIN, St. Joseph’s Health
• Phyllis Wojtusik, RN, Executive Vice President, Health System Solutions, Real Time Medical Systems

This session is part of HIMSS23, South Building, Level 4 | S406 A