Preventable readmissions: The care-transition crisis

Older adults represent nearly a quarter of all emergency room (ER) visits. Seniors also tend to remain in hospitals longer and are readmitted more often than other patient groups. In fact, nearly one in five seniors end up back in the hospital less than a month after discharge.

This care transition crisis costs U.S. hospitals approximately $25 billion every year. To make matters worse, research suggests that 75 percent of these readmissions are avoidable.

To spur hospitals into action, the Affordable Care Act introduced penalties under which hospitals stand to lose nearly $1 billion in Medicare funds in two years if they can’t bring their readmission rates down. With an aging population and rising healthcare costs, an innovative solution is urgently needed.

The need for innovation

Technology, combined with better care-management programs, can improve patient transitions from an inpatient hospital setting to the home setting. Already we are seeing a range of initiatives designed to identify the underlying causes of hospital readmissions and develop innovative strategies to reduce re-hospitalization among vulnerable seniors and people with chronic conditions.

Technology’s role

For physicians and care managers, receiving actionable health data directly from a patient’s home can reduce ER visits and hospital readmissions. Real-time data, especially from the home of a high-risk population of seniors and individuals with chronic illnesses, can reveal developing problems before requiring hospitalization and other more costly healthcare services.

One such technology is eCaring, a unique, cloud-based, care-management system that gives healthcare providers and caregivers access to both clinical and behavioral data from a patient’s home, in real time. The platform’s unique data integration helps care managers determine who is at risk for readmission, offering hospitals protection against the new Medicare penalties, while also allowing patients to live at home longer in greater comfort and at lower cost.

Putting cloud-based care management to the test

In October 2012, eCaring partnered with Morningside House Long Term Home Healthcare to evaluate the system’s potential to improve care coordination for aging New Yorkers. Morningside House, a member of the Aging in America family of providers, oversees five subsidiaries delivering care to thousands of people in the New York City area.

Eight patients (five women and three men) were selected for a trial. All participants were low-income, dual-eligible (Medicare and Medicaid) seniors, over 80 years old and residing in their own homes in the Bronx. In order to rigorously test eCaring’s effectiveness, care managers deliberately chose high-risk, clinically unstable patients with records of frequent hospitalization.

Training for the pilot program took place in early October. Directors, nursing managers and field nurses received orientation training to familiarize them with eCaring’s platform, and clinical staff established user accounts and profiles. eCaring’s system also enabled them to create customized alerts, tailored to patients’ specific health conditions, including both behavioral conditions and ranges of critical vital signs.

Each patient received a 3G-enabled iPad loaded with eCaring’s state-of-the-art care-tracking system. After the patients gave their consent, project coordinators and field nurses conducted home visits to install the device, train the in-home caregiver in data input and discuss patients’ concerns.

Results

After 90 days, the trial’s results revealed a tremendous impact on the care process. eCaring’s Web-based care-management system prevented nine ER visits, three hospitalizations, 12 doctor visits and three unplanned nurse visits – striking results considering several participating seniors had historically visited the ER twice a month.

Such success can be explained by the detailed, real-time data generated by eCaring that allowed Morningside’s clinical staff to monitor, communicate and triage rapid changes in a patient’s status to avoid costly ER visits and prevent deterioration.

The following three examples from the trial speak to the cost savings and care improvement potential of the system. Names have been changed to protect patients’ privacy.

• “Emma” typically made several ER visits every month for high blood sugar and changes in her mental condition. But, since beginning the trial, she has not visited the ER at all. Thanks to an alert for high blood sugar from eCaring, Emma’s care managers were able to address the problem immediately with her caregiver over the phone.
• Historically, “Ryan” would also visit the ER on average twice per month for blood sugar fluctuations. Since he began using eCaring, he hasn’t been back. As in Emma’s case, a high blood sugar alert from eCaring allowed caregivers to take appropriate action early, in Ryan’s home, preventing the need for re-hospitalization.
• High blood sugar and hypertension were the causes for “Maria’s” monthly ER visits, but since starting eCaring, the only ER visit she made was for a seizure not preceded by an aura, which was urgent and unavoidable. During the trial, Maria’s care managers received eCaring alerts concerning her blood sugar and blood pressure, making early intervention possible and preventing any unnecessary ER trips.

Thanks to timely notification and early intervention, a substantial number of ER visits were prevented, presenting significant cost savings to the healthcare system and improved care outcomes for the patients themselves. The savings from services avoided were more than $60,000, roughly $2,500 per patient per month, while the eCaring system costs were around $1,200.

These results indicate the profound impact eCaring’s care-management system can have on reducing healthcare costs, while improving quality for millions of patients with chronic conditions. Such patients include dual eligibles and the growing number enrolled in managed-care organizations, such as accountable care organizations (ACOs), medical homes and managed long-term care plans.

Laura Hernandez, RN, MSN, vice president of home care and director of patient services at Morningside, affirmed the positive experience clinical staff had with eCaring. She cited the ability of care managers and aides to log in, monitor and update a patient’s status in real time as a major improvement to the care-management process. For Hernandez, eCaring also had the additional benefit of verifying that aides are actually with their patients, while ensuring compliance with instructions from care managers.