Closing the Post-Acute Care Communication Gap with Automated Patient Engagement

May 23, 2018

It’s no secret that empowering patients with the right information at the right time improves quality and reduces costs. When hospitals and medical groups that use our solution to have daily dialogues with patients, we see those patients make informed decisions that prevent complications and even potentially life-threatening events. 

That remote guidance and monitoring has delivered concrete results for our customers, including:

  • 64% increase in discharge to home
  • Reduction in Skilled Nursing lengths of stay
  • $656 amortized savings per case

Managing Care Beyond the Inpatient Stay

To-date, hospitals and health systems have largely focused on the services they’re providing, with little control over or insight into what happens to patients who are discharged to skilled nursing facilities, rehabilitation centers, hospices, and other post-acute care settings. That may have worked in the fee-for-service world, where hospitals had no financial responsibility for a patient’s care and service after discharge. However, with the advent of value-based payment models, carefully monitoring utilization of post-acute spend has become a high priority for both hospitals and post-acute care providers.

Today, nearly half of Medicare patients require post-acute care following a hospital stay. And, according to a 2011 Kaiser Family Foundation study, 25 percent of Medicare residents receiving post-acute care from nursing facilities were readmitted to the hospital that year, costing Medicare roughly $14 billion. 

Closing the communication gap between the hospital and post-acute care center has become a business imperative for hospital leaders. Forward-thinking health systems have been taking the necessary steps to narrow their networks and forge collaborative relationships with high performing post-acute care providers to gain more control over quality and cost of post-acute care. 

That’s a step in the right direction. But what has been missing is a technology tool to communicate and coordinate activities between the index facility and post-acute care center, a solution that leverages the patient to provide daily, real-time feedback on his or her progress. An automated patient engagement tool for the post-acute care setting has been the missing link – until now.

Engaging Post-Acute Care Patients and Providers

Illinois Bone & Joint Institute (IBJI) is one of our long-time customers and a leader in delivering high-quality, high-value care through bundled payment programs. In fact, they’re one of the best in the country at managing costs throughout the post-acute care phase.

With IBJI’s business and clinical know-how and HealthLoop’s technology chops, we jointly developed a unifying post-acute care engagement platform to close the communication gap between hospitals and post-acute care facilities. For patients discharged to a skilled nursing facility or other setting, the solution engages the post-acute care provider to carefully monitor lengths of stay and utilization.

 IBJI utilized the solution to participate in a Model 3 Bundled Payment for Care Improvement initiative, called OrthoSync. Before implementation, IBJI established a network of “partner” post-acute care providers for the initiative, which includes all post-acute care for patients undergoing elective hip, knee, and ankle replacements and non-elective hip fracture surgery. The program begins at the start of post-acute care services and ends 90 days later.

A study conducted by IBJI found that elective patients enrolled in OrthoSync cost an average of 13.8 percent less and fracture patients cost an average of 1.4 percent less compared to baseline data. For elective patients where a partner skilled nursing facility was used, hospital readmissions dropped by 3.6 percent and the average length of stay dropped significantly, from 17.6 days to 13.9 days. This study was carried out at six healthcare systems, 18 hospitals, and 46 post-acute rehabilitation providers.  [1] 

As IBJI’s study outcomes illustrate, post-acute care engagement is a powerful tool to facilitate communication and transparency among all members of the care team. It also helps reduce unnecessary care variation and spending that contribute to higher costs. Care team collaboration and mobile-based tools enable cross continuum support of patient populations. Our solution’s risk-stratification and data and reporting capabilities enhance post-acute care performance. 

“We were impressed with HealthLoop’s willingness to help us create a system that is flexible and dynamic and meets our needs in a product and also enhances that with real-time patient engagement and education,” says Julie DiGiovanna, Director of Clinical Services, OrthoSync, Illinois Bone & Joint Institute.

As hospitals continue to assume greater financial risk, an automated engagement platform is vital to support better collaboration between hospitals and post-acute care facilities. Organizations that embrace a post-acute care engagement solution see dramatic decreases in length of stay, hospital readmissions, and complications. Those improvements translate into reduced readmission payment penalties, increased shared savings payments, improved outcomes, and a better patient experience.

Under payment for value, an automated patient engagement platform is a powerful tool to strengthen communication and care coordination between the hospital and post-acute care provider. 

[1] Robb, W., MD; Shah, R., MD; Goldstein, J., MD; Blom, A., PT, STC; Branson, J., RN, BSN, ACM; Fletcher, M.  (2016, Nov.) Moving the Needle: Less Cost, Improved Care From a Gainsharing-Supported Integrated Rehab Network. AAHKS 26th Annual Meeting.  

 

HealthLoop scales the impact of care teams through the power of patients. 

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