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.