How Mobile Care Coordination Can Improve Health Outcomes and Reduce Costs

There will always be a myriad of providers across the care continuum, creating challenges for real-time communications, updates and clinical care.

A survey published in Health Affairs found the primary care physician (PCP) was not informed of the care their patients received in 30% of adult emergency department (ED) visits. This lack of medical information leads to negative health outcomes, poor quality of care, increased readmissions and higher medical costs.

About 1 in 5 Medicare patients discharged from a hospital are readmitted within 30 days, according to CMS¹, costing an additional $7600 per readmission.² More disturbing, roughly 76% of those readmissions could have been prevented with improved communications and better care coordination.¹

Clinicians and care-team stakeholders have their work cut out for them. For patients with high-risk chronic conditions, care coordination is even more crucial to keeping them adherent to treatment plans inside and outside the hospital.

But what if clinicians and all other care-team stakeholders could securely communicate patient updates and coordinate their actions the most relevant information? And what if we leveraged technology so even when physicians or caregivers lapsed in memory, the system would alert others to the mishap?

Roughly 20,000 medical professionals are already using this technology across 50 institutions and healthcare organizations, in several states.

Improving Healthcare Communications Among Providers

Cureatr is a mobile, HIPAA-compliant, cloud-based solution that gives doctors, nurses, pharmacists, social workers and all other stakeholders updates on the care patients receive in real-time. It enables secure, real-time communication between team members across the continuum—both inside and outside healthcare systems and networks. Improved communications are already improving patient care and lowering costs while reducing preventable hospitalizations.

Building Networks for Communication

Cureatr allows clinicians to seamlessly connect the dots—helping them track where their patients are and informing them when a health-related event occurs. Whether a patient is admitted in the ED, transferred or discharged, Cureatr builds Care Event Notification (CEN) networks and delivers real-time alerts directly to the patient’s care team through a mobile and desktop application, or via care system integrations.

In New York, clinicians and staff at leading hospitals and healthcare systems are using Cureatr to navigate complex workflows and to communicate seamlessly across care teams. The platform pulls meaningful data from the electronic medical record system, alerting the right team members with actionable information necessary to better manage and treat their patients.

This seamless coordination is allowing health systems like Mount Sinai to extend beyond the acute care setting and into the communities where their patients live. When any type of clinical event occurs such as an admission to the hospital, discharge, doctor visits, and transitions from the hospital setting to follow-up care, the information is communicated securely to the relevant members via Cureatr’s platform.

Connecting Providers Across Distinct Networks

When patients receive care across a number of different healthcare settings, information and data inevitably gets lost. Typically, clinicians use differing care management platforms, electronic record systems and other patient documentation tools, which can be a significant obstacle to ensuring effective communication and flows of information across care settings.

A core feature of Cureatr’s technology is bringing real-time data and communication solutions to hospitals and providers, even when their systems are not compatible. Cureatr captures digital data from multiple sources and seamlessly notifies members of the patient care team.

The flow of information is multi-directional and agnostic with regard to electronic record system, allowing for coordination internally within institutions as well as externally with others using dissimilar electronic medical record systems or care management platforms. This broadens the network of care, allowing for efficiencies around care transitions and follow-ups that are consistent with the treatment plans prescribed for the patient.

Our data has already shown that with the utilization of Cureatr’s platform, PCP visits increase within 7 days of a patient’s hospital discharge. Early follow-up has been shown to reduce preventable readmissions.³

ACO Use Case

A large accountable care organization (ACO) utilized Cureatr’s CTNs and robust mobile coordination platform to manage and track high utilization patients with chronic conditions. Patient health events, discharge follow-up and care coordination across the continuum were the primary use cases in this population.

In just 1-3 months, coordination of care grew from nurse to doctor into multi-directional coordination between nurse practitioners, physicians, social workers, care coordinators, dietitians and multiple health extenders. As a result, 30-day readmissions declined as did the number of hospitalizations. Across multiple markets, ED diversions increased.

Extending Acute Care Success to the Post Acute Care Setting

In April 2014, CMS approved New York State’s $8 billion Medicaid waiver request to reinvest $8 billion in federal savings to restructure the health care delivery system--with the primary goal of reducing avoidable hospital use by 25 percent over 5 years. $6.42 billion of that funding will go toward the Delivery System Reform Incentive Payment (DSRIP) program.

A large hospital system expanded utilization of Cureatr’s platform to help achieve DSRIP goals in the post-acute care setting. Utilizing Cureatr’s platform and CENs, clinicians tracked, communicated and coordinated care of CHF and COPD patients across HIE, acute care, skilled nursing facilities and Home Health settings.

As a result, care efficiencies were substantially improved and timely interventions for high risk patients were delivered in order to reduce and divert ED visits. During a 1 year period, $4.2 million in savings were achieved by ED diversions alone using Cureatr. In addition, 267 readmissions were prevented and the average length of stay in the hospital for those admitted was reduced.

Conclusion

As the shift toward accountable and outcomes-based care continues to expand, health institutions will need to embrace cloud based technologies like Cureatr in order to improve quality of care and health outcomes. The ability to communicate in real-time is be necessary for doctors, nurses, pharmacists, social workers and all other care-team stakeholders to provide better care and reduce costs.

About the Author

William Winkenwerder, MD, is a board-certified physician and nationally prominent healthcare executive. He served as Assistant Secretary of Defense for Health Affairs and was CEO at Highmark, one of the country’s largest diversified health insurance companies. He is on the board of Cureatr, which Redox recently recognized as one of the top companies driving healthcare innovation.

References

1. James J, Hall K, Joynt KE, Lott R. Health policy brief: Medicare hospital readmissions reductions program. Health Aff. Published November 12, 2013. Accessed October 18, 2017.
2. Quality Improvement Organization Fact Sheet. CMS website. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/Downloads/9thFactSheet_CareTrans.pdf. Accessed October 31, 2017.
3. Sinha S, Seirup J, Carmel A. Early primary care follow-up after ED and hospital discharge — does it affect readmissions? [published online January 17, 2017]. Hosp Pract. 2017; ttp://dx.doi.org/10.1080/21548331.2017.1283935.