Christiana Care Health System cut its Medicare 90-day readmission rate by 30 percent by integrating information technology (IT) into its patient discharge process, Andis Robeznieks writes for Hospitals & Health Networks.
The new discharge program, called Carelink CareNow, coordinates care for nearly 75,000 Medicare beneficiaries. In February, the American Board of Quality Assurance and Utilization Review recognized the program and Tabassum Salam, the medical director of Carelink CareNow, for the program's "robust interprofessional care coordination and discharge planning."
Beyond the traditional model
According to Patty Resnik, VP of care management at Christiana Care, Carelink CareNow enhances and expands upon the system's original discharge program, which she said ended at teaching patients and loved ones about their medicines and other key health information before passing them on to the next health care provider.
But the new program uses a new IT system to go "beyond the traditional discharge model," Resnik said. According to Salam, the IT system—funded by a $10 million grant from the Center for Medicare and Medicaid Innovation—has two major components. First, it has access to the Delaware Health Information Network, and second, it has an analytics component that assesses each patient's medical data, all of his or her medications, and the overall number of comorbidities that patient has to generate a score.
Salam said while all of Christiana Care's Medicare patients participate in the program, the health system focuses on the patients who receive the highest overall scores. That kind of attention, Salam added, extends the health system's reach outside of the hospital, including to the 17 different nursing facilities that Christiana Care has partnered with in the area.
Under the new program, Christiana Care uses the IT system to ensure all participating patients can make their follow-up appointments and to notify patients' primary care providers in real time about any other health care interactions the patient has had. "If any of them have a visit to a hospital or [ED] in the state, we know that they're there," Salam explained.
According to Salam, the Carelink CareNow is staffed by nurses, pharmacists, physicians, respiratory therapists, and social workers. Pharmacists have a particularly important role in patient safety, Salam added, because they reconcile the patient's pre- and post-hospitalization medications.
Salam said traditional discharge programs, which end at preparing the patient and loved ones at discharge, cannot address post-discharge factors that can potentially derail care, such as behavioral health issues, transportation issues, or "the realization that the family lacks the financial ability to pay for medications or devices."
But the new program aims to address such obstacles, Salam said, citing one case in which the health system helped arranged transportation for a patient caring for three grandchildren so that she could focus on her care. "We realized that had to be in place before we could engage the patient herself," Salam said. "So we are that glue—that continuity for our patients" (Robeznieks, Hospitals & Health Networks, 6/15).
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