Using non-clinical workers to prevent hospital (re)admissions
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Data analysis done by Care at Hand using non-clinical workers such as Meals on Wheels and personal home care assistants to prevent hospitalizations and other adverse events
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Using non-clinical workers to prevent hospital (re)admissions
- 1. Andrey Ostrovsky, MD CEO | Co-Founder | Care at Hand andrey@careathand.com Summary of COPD-specific trends from community-based interventions using Care at Hand
- 2. 2 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
- 3. 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 by Nurse 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
- 4. Nurse Care Coordinator Primary Care Provider Visit Emergency Dept/ Admission Home Visit by Nurse 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
- 5. 5 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
- 6. 6 Poor access to care 5x more likely to need arrangement for DME © Care at Hand
- 7. 7 COPD 30x more likely to require education on red flags. 50% more likely than CHF © Care at Hand
- 8. 8 COPD 6x more likely than avg to need to be seen by RN in person, similar to CHF © Care at Hand
- 9. 9 COPD among most frequent active issues © Care at Hand
- 10. 10 COPD has 30% higher risk of hospitalization than average active issue © Care at Hand
- 11. COPD population similar to most other active issues. Poor access to care has higher prevalence of frequent flyers 11 © Care at Hand
- 12. 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
- 13. Skilled nursing involved in over 40% of care coordination episodes © Care at Hand
- 14. Individual staff contribution to outcomes enables real-time targeted promotion and capacity building, decreasing turnover
- 15. Granular hotspotting of highest utilizing and highest projected risk patients
- 16. Thank you! Andrey Ostrovsky, MD CEO | Co-Founder, Care at Hand andrey@careathand.com © Care at Hand
Editor's Notes
- To have an impact, you first need to be able to measure it
- How Care at Hand improves on Coleman – provides patient need-driven care coordination
- How Care at Hand improves on Coleman – provides patient need-driven care coordination
- Poor access to care 5x more likely to need arrangement for DME
- Red flags are warning signs that COPD is getting worse
- Figure 4: Readmission rate in each predicted risk category for the intervention-based risk score from structured data capture
- Figure 4: Readmission rate in each predicted risk category for the intervention-based risk score from structured data capture