To perform well under bundled and value-based care payment programs, it is essential that ACOs and hospitals adopt innovative, cost-effective solutions to improve clinical outcomes and demonstrate savings. Yet, the lack of interoperability between acute and post-acute care (PAC) providers often creates barriers to reaching these goals.
By advancing care coordination efforts with the help of live post-acute data transparency, healthcare organization St. Joseph’s Health System overcame those barriers to strengthen its high-performing PAC network, improving care management across settings while reducing total costs.
But it didn’t happen overnight. With patients being referred and choosing a variety of post-acute facilities, managing the network was challenging. “We had very little information and limited ability to be impactful, not knowing what the trends are and where we needed to focus,” said Margie Latrella, Director of Quality and Clinical Services.
While St. Joseph’s held quarterly meetings with high-performing PAC providers and assigned a care navigator to monitor PAC utilization, it didn’t have the timely information needed to monitor patient progress in the skilled nursing facilities (SNFs) on a day-to-day basis.
There were other challenges too. Like many acute care organizations, St. Joseph’s didn’t know when patient conditions changed in the PAC setting and couldn’t determine which patients were at risk for rehospitalization or who was being discharged. Tracking readmissions data on spreadsheets and relying on disparate EHR systems and outdated claims information didn’t reveal timely clinical insights either – narrowing St. Joseph’s ability to influence care.
A lot of questions were left unanswered. Why were one in four patients returning to acute care? Were those readmissions stemming from a particular facility or certain physicians? What were the patients’ standing orders? Were the SNFs having trouble managing certain diagnoses? Are they actively working on discharge plans? Who is deteriorating? Who is transitioning home?
The Answers Lie in Live Data and Post-Acute Analytics
After learning about Real Time Medical Systems (Real Time) at a conference, Latrella turned to its post-acute analytics solution for answers. “The prospect of being able to watch our patients’ status every day of their post-acute stay was amazing,” she said. With Real Time, Latrella and her team gained immediate, clinical line of sight into their patients’ care within the SNFs.
But how would the SNFs respond? Initially they were hesitant to adopt the solution, but Latrella said that once they understood how Real Time would benefit them, especially in prioritizing care, reducing readmissions, and improving Star ratings, they were on board.
Today, nine PAC facilities are connected to St. Joseph’s via Real Time’s cloud-based platform, enabling the nurse navigators managing the value-based contracts to access live patient data from the PAC’s electronic health records. Through interoperability, live data analytics, and hospital readmission risk stratification, St. Joseph’s can now identify subtle changes in patient condition as they occur and prioritize high-risk patients by clinical need. Because the platform pushes live clinical alerts and suggested interventions to the care teams at both St. Joseph’s and their PAC network providers, everyone is working from the same data, in real-time, to improve quality care.
With the ability to risk stratify patients, St. Joseph’s care navigators immediately know who is at risk based on easily interpreted indicators. The navigators also know why a patient triggers a risk alert and can quickly collaborate with the SNFs regarding changes in patient condition and course of treatment.
Data-Driven Collaboration Leads to Improved Outcomes
Having immediate access to live patient information helped St. Joseph’s manage care alongside their PAC facilities as a collaborative effort. “It really opened up the doorway to a more collegial relationship with our post-acute facilities,” Latrella said. “And as a result, we improved outcomes.”
Latrella explains that post-acute data transparency has enabled St. Joseph’s to better manage the PAC network and significantly reduce readmissions. With up to the minute reporting, the ACO has readily available data to evaluate providers, compare facility metrics, and determine savings.
“We reevaluate our network twice a year based on readmission rates, length of stay, Star ratings, citations, and clinical programming,” she said. Because the SNFs want to be included in St. Joseph’s high performing network, they use the live data to demonstrate quality of care so they can stay in the network. This information has helped St. Joseph’s establish care standards, improve transitions, and increase post-acute referrals to the high performing network.
St. Joseph’s has also facilitated more open communication among their high performing network providers themselves. They now have monthly roundtable discussions where the SNFs share best practices and conduct case reviews, which has transformed their meetings from a competitive climate to a collaborative one. “We all have a common goal,” said Latrella, “and that is quality care for the patient.”
To learn more information on how St. Joseph’s leveraged live post-acute patient date to strengthen their preferred PAC network, achieve $1.6M in savings, and improve outcomes at the patient and facility level, download the St. Joseph’s case study today!