Despite widespread adoption of electronic health records at hospitals and (to a lesser extent) post-acute care facilities, care coordination and outcomes monitoring among both types of providers are still often a big challenge.
For example, patients discharged to skilled nursing facilities and other PAC sites experience a 22.8% readmission rate nationwide, compared with 13.9% for all discharges.
THE CHALLENGE
TriHealth, a four-hospital not-for-profit health system and accountable care organization in Ohio with 140 care sites and a network of more than 200 skilled nursing facilities, sought to reduce those readmissions and help patients safely return to their homes sooner.
But the health system had limited awareness of its patients' health and status at PAC facilities due to antiquated monitoring methods that typically involved sending faxes and making phone calls.
Once patients were discharged to an SNF from one of the hospitals, visibility into their health status and trajectory was limited and inconsistent, significantly reducing staff's ability to intervene promptly, said Lori Baker, director of population healthcare management and post-acute network at TriHealth.
"This was primarily due to the tedious administrative steps and convoluted processes required to obtain clinical updates, typically through phone calls and even faxes," she explained. "As such, our readmission rate from SNFs reached 25%. Our patients' length of stay at SNFs was 25 days on average.
"As an ACO, we knew this post-acute care transition and coordination process was not a sustainable model if TriHealth was going to succeed in any value-based care payment program in the future," she added.
PROPOSAL
The ACO leadership team went to Baker with a goal to reduce the readmission rate from 25% to 20% and, likewise, the LOS from 25 to 20 days on average, which, at the time, Baker thought was unrealistic.