Improving patient outcomes while reducing readmissions with data analytics
Abstract
As post-acute care spend continues to rise and the Centers for Medicare and Medicaid Services (CMS) moves forward with promoting both value-based and risk-bearing models of care, it is essential for accountable care organisations (ACOs), payers and hospital providers to take proactive measures to find innovative and data-driven strategies to meet the future demands of healthcare. Yet disparate electronic health record (EHR) systems between acute and post-acute providers continue to pose challenges in the ability to access live patient data across care settings, which enables clinical line of sight to manage both patient and population-level quality outcomes. Utilisation of an EHR-agnostic platform, which mitigates interoperability issues, can improve care transitions, provide data analytics to manage the patient care journey, foster seamless implementation of standardised care pathways and ultimately reduce total costs within post-acute networks by decreasing readmissions and length of stay. St. Joseph’s Health implemented such a data analytics platform and instituted a post-acute nurse navigator, social worker and care manager roles to manage their value-based patients in the postacute setting. As a result, their Medicare Shared Savings Plan ACO, Mission Health Coordinated Care, achieved a significant reduction in readmissions from 24 per cent to 17.8 per cent, as well as a total cost of care savings of US$1.6m in its first year. Currently, the readmission rate is down to 13.6 per cent, and there has also been a 3.2-day reduction in average length of stay. Owing to their successful post-acute strategy and programming, the project was scaled to include all patients in value-based contracts.
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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.
Citation
Latrella, Margie and Baldasare, Lavana (2024, March 1). Improving patient outcomes while reducing readmissions with data analytics. In the Management in Healthcare: A Peer-Reviewed Journal, Volume 8, Issue 3. https://doi.org/10.69554/RITW9729.
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