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From Hospital to Home: A Service to Reduce Readmissions Built Around Engaging Patients

June 28, 2013
by Rajiv Leventhal
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As hospitals face increased pressure to reduce readmission rates, one consulting company might have found an answer
Dyke Hensen

Readmissions continue to be a significant concern for hospitals, as they will receive cuts to their Medicare payments for higher-than-expected readmission rates for certain diagnoses.

Last year, Medicare began levying financial penalties against hospitals with avoidable readmissions under a mandate from the Affordable Care Act.  And although federal officials say that readmission rates have dropped, repeat hospitalizations can still be avoided far more frequently. While many readmissions are not avoidable, others are the result of gaps in care management, particularly in post-discharge follow up.

To this end, Vree Health LLC, a North Wales, Pa.-based subsidiary of Merck Sharp & Dohme Corp., based in Whitehouse Station, N.J., and a consultant in helping redesign processes surrounding readmissions, offers TransitionAdvantage, a post-discharge service designed to help hospitals reduce preventable 30-day patient readmissions. By engaging patients on a daily basis and improving coordination across care providers, TransitionAdvantage is designed to help patients adhere to the hospital’s recommended post-discharge care plan. 

The service is on the verge of being implemented in Griffin Hospital, a 160-bed acute care community hospital based in Derby, Conn., and Vree has also partnered with Frontier Medicine Better Health Partnership (FMBHP), a Montana-based partnership and learning collaborative.

The core of the TransitionAdvantage service is a scalable, flexible, cloud-based electronic patient profile, seamlessly populated initially by an electronic medical record (EMR), and updated throughout the 30-day post-discharge period with patient health information. The system integrates and aligns with the hospital’s current processes and technologies to extend its reach and provide connectivity across the entire care team.


The solution, says Dyke Hensen, senior vice president at Vree Health, combines an innovative data sharing and care coordination platform with the individual attention of a Transition Liaison, who helps reinforce patient compliance with their prescribed care plan. Furthermore, powerful technology provides relevant and timely data to enhance the quality improvement processes.

“We’re trying to fill in a lot of gaps that happen when someone leaves the hospital,” Hensen says. “We want to put in place a formal follow-up system and share that to the extended caregiver network as well as tying in the primary care providers and the information back to the hospital. It really is about care coordination and hopefully some positive behavioral change with a lower cost approach.”

This is how the process works, explains Hensen: “When a patient is sitting in the hospital, about to be released, one of Vree’s people will go through a preliminary health check [with him or her]. What we have in the background is a care plan that was developed with the help of Merck’s medical staff and it walks through a set of check points, both hard data and soft data. This includes things like blood pressure, weight, dizziness, and energy level. It’s about a 5-7 minute checkup, which could happen in a couple of different modes:  through an outbound call; on the web; or via a voice service.  This service lasts from 14-30 days.”

And nurses and physicians get the summary reports on a dashboard setup. It’s designed to be an easily consumed interface—not like looking at an EMR system. It’s a web-based set of screens and it’s not onerous, Hensen says.

Vree recommends in its service that the checkups happen every day, but there are hospitals that suggest every other day is more preferable, so whatever the hospital’s follow-up plan of care is, Vree adapts the system to accommodate it, Hensen says. “We’re making an abbreviated patient profile—a combination of pertinent EMR data along with our interactions with the patient. And this is all connected in real time online. So if an alert in the system goes off signaling a change in health status, a Transition Liaison will immediately make a call.” Vree’s call center has been trained in behavioral and motivational communications, says Hensen, adding that motivational techniques will often help patients, and the Liaison will eventually determine if the situation needs to be escalated to the nurse line or hospital.

While Vree has been working on the TransitionAdvantage design for more than two years, the design criteria have changed a little, Hensen says. “When first designed, it was all about everything we could do to reduce readmissions. And that’s still the main goal, but what we have learned over time is more of an emphasis on sharing data, and collaboration with other care networks. As we have worked with the product, it’s not just about filling the gaps when a patient leaves a hospital to when they come back, but the gaps that happen after that, too. Are they going to a nursing facility or back home? Do we need to extend a user interface to a caregiver if it’s a spouse or child? These are questions we needed think about during design.”

Helping patients transition from hospital to home is a major challenge that requires providing individual attention for each patient after they leave the hospital, and Hensen stresses that the technology could not work without the patient engagement aspect. “That is the vital part to this,” he says. “When a hospital releases a patient and is blind to what is going on with him/her, the patient may not understand the discharge and the hospital may never know if the patient is taking the required medications. You only know their status and condition when they’re NOT doing well, and that’s not the goal. We think the notion of having this health check on a daily basis will give us a big jump on things before there is an emergency or before there’s something that would cause a readmission.” Hensen warns that while all readmissions cannot be prevented, “there is a lot of hard and anecdotal information that we’ll get before that patient is really symptomatic of being ready to come back to the hospital.”

And while Hensen wouldn’t get too specific with numbers, he says that Vree expects to reduce the amount of avoidable readmissions to meet the requirements of the [mandatory] the Centers for Medicare & Medicaid Services (CMS) Readmissions Reduction program. “Our goal is to be above 20 percent reduction [with TransitionAdvantage]. That’s not a promise, just a design goal, and in reality, we want to be even higher than that.”

Hensen says that Vree’s readmissions design essentially operates on a four-area approach: filling in the gaps, monitoring follow up, improving medication, and care coordination. That’s not the end all be all though, he says. “When we come in and do the consulting, we’re not consulting on how to do readmissions or follow up, but instead we’re looking at hospitals’ goals and the program they are following, so we can show them how to integrate multiple services to support that program. Trust me, the last thing a hospital needs is another major project. But we tell hospitals, it’s not just technology, it’s the integration of these different services, and it’s not a lot of weight on your shoulders.”

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