Improving patient outcomes while reducing readmissions with data analytics

Author's Biography

Margie Latrella Margie brings more than 30+ years’ experience as an acute care registered nurse (RN) and cardiac advance practice nurse (APN) in both hospital and physician practices to Real Time. Previously, she applied her clinical experience to her administrative role at St. Joseph’s Health, focusing on clinical programming, quality improvement interventions and reporting for value-based programmes. Margie demonstrated success in total cost of care savings in two-sided risk agreements, including Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) and Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (CMS CMS BPCI-A) programmes, by developing collaborative workflows and comprehensive care coordination necessary for success. She also led technology implementation to monitor patients in skilled nursing facilities, which played a major role in reduced readmissions and decreased length of stay in post-acute care (PAC) facilities. Both physiological and social determinants of health were considered to ensure programming results in highquality outcomes across the continuum of care, as patients transitioned from hospital to PAC and as they managed chronic and complex disease processes at home.

Lavana Baldasare With a diverse background that includes registered respiratory therapist, certified asthma educator, COPD programme manager, and business manager of The Center for Burn and Wound Healing, Lavana brings more than 28 years of healthcare and management experience to her role at St. Joseph’s Health. Recently named manager of clinical transformation in the Clinically Integrated Network, she utilises her past experiences working closely with both New Jersey Delivery System Reform Incentive Payment (NJ DSRIP) and CMS’ BPCI-A programmes, to effectively oversee a team of RN navigators, case managers and community health workers focused on population health management. Responsible for developing collaborative workflows, overseeing quality of patient care in the post-acute arena and managing the high-performing post-acute skilled nursing facility network, Lavana looks forward to continuing the current successes St. Joseph’s Health has had with increasing positive patient outcomes while reducing total cost of care for the hospital.