A patient’s healthcare experience is usually made up of many individual, isolated encounters with different providers. While there may be some effort to share data among providers, it is still mostly passive; the data is simply incorporated into the electronic health record (EHR), where it may or may not be reviewed or considered.
At the St. Louis-based Ascension Health, operational leaders have dramatically reduced readmission rates for chronic conditions with centralized approach and help from the Plano, Texas-based Vivify Health. Ascension Health, the largest nonprofit health system in the U.S. and the world’s largest Catholic health system, operates 165 hospitals in 29 states.
What Ascension leaders have learned is that simply sharing data isn’t enough to change the quality of care and put the patient at the center. This is why a simple process was implemented: patients call a single phone number for all their health requirements, whether it’s finding a physician that fits their needs, scheduling appointments, coordinating patient admissions, obtaining transfers and provider referrals, or even determining whether a current health issue requires a visit to the emergency department (ED), or an urgent care clinic, or if the heath issue can wait until the primary care physician’s office is open in the morning. And now, rather than patient care being split across multiple, independent providers and locations, it is fully coordinated across all of a person’s providers. In fact, there is no way to enter or exit the Ascension Health system in Texas except through the Good Health Solutions Center.
This has led to the following results: a patient adoption rate of 84 percent; a dramatic lowering of the readmissions rate for the enrolled patients, from 28 percent to 2 percent; and a total enrollment to date of 5,500 patients.
Recently, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed Mark Steiger, director of operations at Ascension Connect, the division of Ascension Health that is operating this set of services. Below are excerpts from their interview.
How is Ascension Connect operated? Where are you located?
Right now, we’re operating in 14 hospitals in Austin and Waco, Texas; I sit in a 33,00-square-foot connection center in Austin. We’re operating a centralized call center and virtualized care. Vivify is the tool we’re using for remote patient monitoring and virtualized care services. We deploy Vivify tools to homes, and provide a high level of intervention for patients, in a multidisciplinary way—a high-touch intervention through patient engagement. That looks like a nurse-led intervention where we’re monitoring your biometrics and connecting with you via two-way video.
This is a home-connected telehealth program, then?
Yes.
Is this program being operated right now only in Austin and Waco?
No, we have hubs that support multiple states. Out of Austin, we’re monitoring patients in Alabama, Wisconsin, Tennessee, and Texas, and we’re beginning to expand and scale and spread.
Ascension Connect was formed in January of this year, but we had been providing care management leveraging Vivify care management for two years. We initially worked only in Texas, but now we provide an offering intended to cross geography.
The core idea was to do telehealth in patients’ homes, then, correct?
We knew that certain populations, for both clinical and social reasons, were especially fragile, and vulnerable to readmissions or failure to thrive, with CHF, etc. And we knew that tools like home health can only go so far, and we wanted to extended care into the home, with much more robust and tactile tools. Health systems have been calling into the home forever, and we had too, but we wanted to reach into the home with biometric alerts.
What types of tools have been placed into homes?
What we do is that we deploy a kit to the individual home: we ship it directly, based on the disease that the individual patient has. We send the patient a cellular-enabled tablet with two-way video, with scale and blood pressure cuff, to your home. For a diabetic, it might be a glucometer and a spirometer, if the diabetic also has COPD (chronic obstructive pulmonary disease). And the kit is programmed to prompt a care pathway customized to the patient’s chronic disease or diseases, and they we set limits for the biometric parameters to make sure that if your blood pressure spikes or your weight increases quickly, it alerts the nurse navigators, who know how to sort their interventions based on acuity. And if I’m a nurse and have a panel of, say, 100 patients, five might be red, 15 might be yellow, and the rest green, and they’ll know how to prioritize interventions.
I have a team of eight nurses, and we’ve deployed around 2,000 kits total, and so they’re going out and coming back in. We usually have about 500-750 deployed at any given time. In total, we’ve touched about 2,000 patients. And the nurses are licensed in multiple states, so that they can manage patients in multiple states.
What have been the lessons learned so far?
The lesson learned is that it’s important to customize this as much as possible so that the patient experience feels highly individualized. And we try to make sure that both the interventions and experiences with the tool, are very customized to the individual patient’s condition.
Is there anything technological that we should know?
We made a choice that maybe other health systems didn’t, to make the tablets cellular-enabled, so that data and connectivity wouldn’t have a barrier to adoption. There is an option where the patient would have to enable connectivity themselves, but we decided to take on the expense of connection. And you can imagine that your bigger challenges are bigger things, like deploying kits to homes, and practical issues, that we’ve had to work out as well.
Let’s talk about the metrics involved.
Yes, 5,500 patients altogether have been care-managed through this program. Meanwhile, our control group for readmissions remains at around 28 percent in terms of readmissions, while the managed group is at 2 to 5 percent in terms of readmissions.
That’s great. Why do you think you achieved that level of readmissions reduction?
I think it’s a very intensive intervention. If you think about it, you might have a 20-minute engagement every single day with a care team. And someone on that trusted care team is there. And if you’re a CHF patient and you have an untreated, rapid weight gain, you’re likely to land in the ED and be readmitted. If we can intervene very early—you’ve got a nurse who’s always quarterbacking. And in any four-month engagement, she may have set up encounters for you with nutritionists, social workers, behavioral health, pharmacists—the whole spectrum of caregivers, including also physicians and nurse practitioners. So they’re all participating in that, and it would be much harder to deploy those kinds of folks, without technology.
What would you tell CIOs, CMIOs, and other healthcare IT leaders, about this?
I think that this is an early indicator that continued and organized remote clinical surveillance deployed to the home can really fulfill the spirit of intention in value-based care, and as technology becomes cheaper, faster, and easier to deploy, building these systems will be essential. Think about all the people who are wearing watches and carrying phones that can track activity and other data points. We want to be there, and have patients have us be a partner in their care around the kinds of things that can be reported. We know that this is phase one of many; we also know that building the infrastructure takes a lot of analysis of best practices, and time and energy and commitment to build. And we invested that energy into this, so that we’re ready for the future, as technology continues to evolve.
Eventually, you’ll expand this to all Ascension markets, correct?
Yes, absolutely. And I have colleagues sitting in Indianapolis and Nashville who will be aligned to do this. So yes, we’re committed to continuing to spread and scale this across all our markets.
