Southern Indiana-based Deaconess Health System has been among the top-performing Next Generation accountable care organizations. Yet believing there was still room for improvement, its population health leaders recently deployed a care-collaboration platform that connects physicians with skilled nursing facilities (SNFs) in their post-acute network. In some facilities, it has already helped cut length of stay by as much as nine days.
Evansville, Ind.-based Deaconess provides healthcare services to 26 counties in Indiana, Illinois and Kentucky.
Lori Sieboldt, M.D., M.B.A., medical director of population health, said that Deaconess began its value-based care and population health journey in 2106. The integrated health system hired Shelly Evans as a post-acute care manager. “She did phenomenal work pulling together the post-acute care facilities and helped them develop a collegial relationship, because Deaconess does not own any of these facilities. Some are chains, while some are mom-and-pop operations. So just opening up a dialog was a great step,” Sieboldt said.
Then Deaconess developed a post-acute care nurse practitioner program. Evans contracted with a few facilities to allow four Deaconess embedded nurse practitioners to work on site. Each nurse practitioner is responsible for two facilities. “They take care of any acute issue that would develop and only transfer that patient to the hospital when the patient warranted that care,” Sieboldt said. “That program had phenomenal results.” In the 2016 timeframe, the initial lengths of stay were in the upper 30s or even low 40s for some facilities. “Within two years of this program, we have been able to decrease the length of stay in these facilities to closer to 17 to 20 days. We had so much success that we added four more nurse practitioners and more facilities. We are now up to 18 facilities.”
Huge Post-Acute Care Footprint
Nevertheless, that left a lot of sites without nurse practitioners. “We are the only regional center for this very large rural population, Sieboldt explained. “There is really nothing between St. Louis, Louisville, Indianapolis and Nashville of any size besides us,” she added, “so our post-acute care footprint is pretty large, with patients going out to over 160 facilities and we only have those nurse practitioners in a small footprint closer to our region. We realized there was this enormous black box of care that we had no impact on, no control over, and where we had no ability to control the quality of care our patients were receiving. That is when we started looking for an IT solution.”
The Deaconess team thought there had to be a way they could touch these patients at these outlying facilities, and have some ability to influence their care. Sieboldt noted that there are a handful of really good IT solutions for this niche on the market, but a company called Olio stood out for a few reasons. “One is that it is located here in Indiana – in Indianapolis. They were new enough that they were very willing to personalize and build specifically for our needs, yet experienced enough that they had a track record of success with two large institutions in Indianapolis,” she said. “They were looking to expand their foot print in Indiana and we were looking for a solution. They already had their Olio product in some of the southern Indiana facilities we overlap with. It just made sense to us.”
Although Deaconess initially contracted with Olio to use it as a communications platform, it has since added some EHR integration. “It was a neutral third party that the nursing home EHR and our Epic system could connect with in a HIPAA-compliant manner,” Sieboldt said. “But just in the last week, we have added an ADT [admission, discharge and transfer] feed that goes directly into Olio, so it is easier for the nurses on our side and the nurses on the nursing home side to get the appropriate patient information. It decreases the amount of manual data input, and decreases errors. It is about improving quality of care, so anyplace we can decrease risk of error, the better for the patient.”
In addition to daily progress notes about patients, Olio offers the SNFs an escalation opportunity. When they see a patient deteriorating or if they have an urgent question for the medical staff, they can put in an escalation. Olio is a web-based platform but has a HIPAA-compliant mobile phone option. “If one of the nurses has a problem and they put an escalation in, I would get a text message with a red border on it that shows up on my phone that says, Dr. Sieboldt, xyz nursing home has an escalation concerning one of your patients,” she described. “I know to either go to my mobile app to look up that patient or go to the nearest workstation and see what the problem is.”
When the COVID emergency hit, Deaconess extended its Olio contract beyond its ACO population to include more lives. “We realized what a valuable tool the escalation was, so we extended it to all our Deaconess lives,” Sieboldt said. “We were able to intercept some of those escalations and treat those patients in place. That is safer care because we are not exposing them to transportation or the hospital environment, and safer for the healthcare workers, because we had fewer people exposed to potentially COVID-positive patients or people under investigation.”
Deaconess went live with Olio in January 2020, but Sieboldt said they have already seen progress. “I see the best movement in places where we do not have embedded nurse practitioners,” she said.
Sieboldt put the nursing homes they work with in three buckets: In the first are nursing homes that have their nurse practitioners embedded and use Deaconess’ 24x7 nursing triage hotline. “We have really good arms around the quality of care that goes on in those facilities,” she said. In the second bucket are ones that do not allow Deaconess’ nurse practitioners in, but do use the triage hotline; the third bucket does neither. “That third bucket is where we are seeing enormous progress,” she said. “We have been able to decrease length of stay in that third bucket by almost nine days in the first three months, according to the Olio data. I do not have my Deaconess data for that period yet, because population health works through claims data, so I won’t be able to verify their data until I get my claims data in, but early results do seem to substantiate the data Olio has provided me.”
Sieboldt points to several factors for this improvement. “With the nursing homes giving us daily updates, we can see into their day-to-day care of that patient,” she said. “We are careful to always respect their autonomy and the care they provide, but we are able to suggest things. If a patient is lingering in the nursing home due to inability to transfer safely, our nurse might be able to ask if they have considered another therapy or an assistance device. I think the ability for them to reach out and get immediate answers through escalations helps decrease the readmissions. I have been very pleased with what I have seen in first six months of usage.”
In fact, Deaconess is starting to think about expanding the use of Olio to home health. “We are beginning to have conversations with a local home health agency that cares for a substantial number of patients in our areas, but we are still at the administrative discussion stage about that. It is a way for us to peek in and keep an eye on our patients and just have that soft touch. We want to respect the autonomy of the patient-physician relationships they have. We are simply augmenting that by having another set of eyes on the patients, because we know physicians are stretched and have large patient panels and we are offering another set of eyes to make sure overall trajectory of care is going in the direction the patient wants, the family wants and the physician wants.”
