Using non-clinical workers to prevent hospital (re)admissions
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Andrey Ostrovsky, MD CEO | Co-Founder | Care at Hand [email protected] Summary of COPD-specific trends from community-based interventions using Care at Hand
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Transcript of Using non-clinical workers to prevent hospital (re)admissions
Andrey Ostrovsky, MDCEO | Co-Founder | Care at [email protected]
Summary of COPD-specific trends from community-based interventions using Care at Hand
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Summary of data
• Data collection period 5/2014-5/2015 (1 year)
• Total number surveys administered: 10,202• Average age: 71• Most data collected in care transition setting
Before Care at Hand – communication breakdowns between nurse and nonclinical coach
Personal Care/Home delivered meals
staff
Nurse Care Coordinator
Primary Care Provider Visit
Emergency Dept/
Admission
Home Visit byNurse
Care coordination 3
© Care at Hand
Organizations pay for and underutilize 5 million non-clinical workers in attempting to reduce $250 BILLION in avoidable costs
Nurse Care Coordinator
Primary Care Provider Visit
Emergency Dept/
Admission
Home Visit byNurse
Care coordination
Alerts triggered by Care at Hand technology
4© Care at Hand
Digitizing the “hunch” of non-clinical workers to detect early decline
Personal Care/Home delivered meals
staff
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Non-clinical workers reduce costs, predict readmissions
AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD. 2014.
Estimated Net Savings
© Care at Hand
$2.57 net savings for every
$1 invested
$109 savings per member
per month
39.6% 30 day readmissions
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Poor access to care 5x more likely to need arrangement for DME
© Care at Hand
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COPD 30x more likely to require education on red flags. 50% more likely than CHF
© Care at Hand
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COPD 6x more likely than avg to need to be seen by RN in person, similar to CHF
© Care at Hand
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COPD among most frequent active issues
© Care at Hand
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COPD has 30% higher risk of hospitalization than average active issue
© Care at Hand
COPD population similar to most other active issues. Poor access to care has higher prevalence of frequent flyers
11© Care at Hand
Patients with COPD less likely to discharge home with skilled care than those with medication management issues. Poor access to care significantly higher risk of d/c to SNF
© Care at Hand
Skilled nursing involved in over 40% of care coordination episodes
© Care at Hand
Individual staff contribution to outcomes enables real-time targeted promotion and capacity building, decreasing turnover
Granular hotspotting of highest utilizing and highest projected risk patients
