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Improving Patient Transitions with Nurse Oversight via Care at Hand mHealth: Elder Services of the Merrimack Valley

Rationale / Objectives

ESMV wanted to provide their non-clinically trained health coaches with nurse oversight to deliver better quality clinical support to patients transitioning from the hospital to the home environment. They wanted to balance the lower-cost, accessible-availability of field-based health coaches and support workers with the superior clinical skillset of higher-cost, lower-supply nurses. ESMV expected that improved quality assessments of transitioning patients would more accurately evaluate their risk status. This process would present care providers with the opportunity to give appropriate preventive care, and in doing so, reduce readmissions.[1][2]

Project/Program Description & Major Achievements

ESMV implemented Care at Hand in July 2013. The program initially recruited patients who had been admitted to hospital three or more times in the previous year. After four successful months, the program involved all transitioning patients. Mobile devices equipped with Care at Hand provided simple, plain-language: 3-minute surveys appropriate to the patient’s condition. Medical or psychosocial warning signs were flagged. Algorithms built into Care at Hand assigned a risk score that determined the care pathway, in terms of recommendations, care duration and other criteria. The Nurse Care Manager was informed in real time via text and email alerts if anything was out of range or signaled a potential decline in the patient. Hospital readmissions fell by 39.6%. Over 6 months, 496 alerts were issued, resulting in Medicare net savings of over half a million dollars.[1][2]

Lessons Learned

Care at Hand enabled ESMV to bring triage capabilities into a patient’s home even in the absence of a nurse. The real-time data provided by mobile technology proved ideal for carrying out the Plan Do Study Act cycle that led to process improvement. Patient tracking and management were improved. Identification of the highest risk patients was made possible. Additionally, patients and health coaches could be better matched to improve the patient’s experience. There were net savings due to reduced readmissions, in spite of the costs associated with implementing the program.[1][2]

Further Description

The Centers for Medicare and Medicaid Services (CMS) Care Transitions Program called for a reduction in hospital readmissions for patients who were in between care settings. CMS needed to facilitate access to the clinical expertise required for high-quality patient assessments (to identify high-risk patients) in spite of an undersupply of nurses. To do this, Elder Services of the Merrimack Valley (ESMV) employed the mobile technology solution offered by Care at Hand. ESMV is an Area Agency on Aging (AAA) based in Lawrence, Massachusetts. They transformed their care transition model in 2013 using Care at Hand. This predictive mobile technology product that was built on the Agency for Healthcare Research and Quality’s (AHRQ’s) Care Coordination Measures Atlas, has led to a 39.6% reduction in ESMV’s Medicare patient thirty-day readmission rate.1

Major Achievements

Metric Result Detail
Hospital readmissions Dropped by 39.6% (relative difference), 10% (raw difference) After 6 months1
Medicare net savings $567,071 Over 6 months1
Alerts issued 492 (9% of these resulted in a visit from a nurse) Over 6 months1