Home Care Technology Report's Tim Rowan interviewed our SVP of clinical transformation, Cyndi Rizzitello, in regard to our new case study with Encompass Home Health and Hospice. The home health and hospice powerhouse is leveraging our analytics technologies to reach the Triple Aim. Tim's article focuses on Encompass's use of our Nurture solution to help manage and best care for discharged patients. Check out the full article here:
A new predictive analytics system has brought better patient outcomes and stronger revenue growth to nine branches of 30-state Encompass Home Health and Hospice. The results were so significant, management is set to expand use of the tool to all 225-branches.
One of a Medicare HHAs challenges is maintaining and growing census in an intensely competitive market. The manager's nightmare's is losing patients to other agencies. Sometimes it happens when they have a hospital admission in the middle of a home health episode and remember only that their nurse was Nancy. More often, it happens by losing contact with them after discharge, never knowing when they might need to come back on service, only to learn later they wound up in the hospital or with a competitor.
Calling every discharged patient every day would solve the problem but be a prohibitively large and expensive undertaking. This is where predictive analytics can help. Encompass ran its 9-branch pilot using Nurture, from Nashville-based Medalogix. The company was already familiar with Medalogix after using two of its earlier analytics products, Bridge and Touch. We spoke with Cyndi Rizzitello, VP of Clinical Transformation at Medalogix.
"Nurture uses OASIS assessments and other EMR data to create models that accurately identify the risk that any one discharged patient is likely to need additional care," she told us. "At discharge, the Nurture report rates each patient as low/medium/high risk. This allows an agency to focus its callback program to keep a patient from going to the hospital or to a competing home health agency."
Nurture consists of a discharged-patient monitoring tool that facilitates contact with patients who are most likely to need in-home care again. When the prediction comes true, the originating agency brings them back before a primary care or hospital physician can refer them elsewhere.
Ms. Rizzitello explained further that this system helps facilitate patient satisfaction, which in turn helps improve HH-CAHPS scores. "If there are any miscommunications or confusion on the part of the patient before the arrival of the HH-CAHPS survey, they can be identified and resolved during the periodic phone checkups." Nurture can also be customized to pop patient names to the top of the call list at specific milestones, such as at 30, 60, 90 and 120 days or on specific dates that are significant to the patient.
According to the case study that describes results of the Encompass pilot, and to Ms. Rizzitello's blog piece on the Medalogix web site, the nine Encompass branches began to call high-risk patients first and found that Emergency Department utilization and hospital admissions can be intercepted. When they needed more home health services, more patients returned to the same Encompass agency, where clinicians and aides were already familiar with their conditions and unique needs.
The Encompass experience
In April of 2016, Encompass began using Nurture in nine home health branches. While they did have an existing discharge calling program in place, new advantages that surfaced included:
- New admission generation: In the first nine months of use, Nurture has facilitated more than 5,000 patient contacts, resulting in identification of 276 patients in need of home care.
- Earlier identification of customer service-related issues: Post-discharge calls give patients the opportunity to discuss their level of satisfaction with the care provided by Encompass. It also presents the opportunity to clarify or intervene on any issues that were unresolved prior to discharge, before the patient has been presented with a satisfaction survey.
- Assurance that the right patients are being called at the right time: Nurture risk stratification groups patients according to their potential to need additional care. This allows Encompass to stay in closer touch with those patients at highest risk post-discharge while waiting longer to call others. This has allowed for better resource management as well as earlier identification of those most in need.
- Ease of managing and tracking calls: Because Nurture has a built-in scheduling and follow up system, Encompass callers always know which patients have already been called, which of those need additional calls and which need referral to home health or other levels of care.
"Nurture has helped us become more efficient by narrowing our focus on high risk patients who may benefit from touchpoints after discharge," stated Janice Riggins RN, Encompass vice president of clinical transformation. "Patient care does not stop once discharge has occurred. By quickly identifying patients through the Nurture risk stratification, we are able to intervene at different milestones to mitigate avoidable emergent care situations and provide the right care at the right time."
Encompass already had a guiding principle known as "a better way to care." But they experienced challenges, common to most agencies.
- Identifying discharged patients who need additional touchpoints to prevent rehospitalizations and improve outcomes.
- Identifying patients who could benefit from hospice care.
- Identifying discharged patients who could benefit from additional home health care.
Even once identified, the challenge remained to develop a solution to manage and monitor these subsets of patients. "By leveraging Medalogix’s predictive analytics and clinical workflows," Ms. Rizzitello concluded, "Encompass is able to apply a clinical transformation approach to its guiding principle."