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@ShahidNShah
@ShahidNShah
The Value of Bridging the Data Gap Between Acute and Post-Acute Care
When acute care providers look at hospital readmissions, it is natural to think about what is being done once the patient is discharged. However, what many forget is that a large portion of patients are discharged to a post-acute facility. In order for post-acute care teams to address things like readmissions and length of stay (LOS), it is essential for acute care providers to create collaborative relationships with their post-acute partners. This includes sharing of data between organizations. Plus, this need is even more apparent when an acute care organization is engaged in value-based care contracts.This was one of the key learnings I found in this amazing case study published in the Management in Healthcare Journal, titled “Improving patient outcomes while reducing readmissions with data analytics”.
Medigy Insights
To solve the problem, St. Joseph’s Health utilized a post-acute EHR agnostic analytics platform from Real Time to view live data for patients who were discharged to their SNF network providers. This data was reviewed by their post-acute nurse navigator to better monitor discharged patients and proactively address those at highest risk for a readmission. One of the key components was a daily report that risk stratified patients, using 400 clinical indicators to help the nurse navigator prioritize their efforts. A report like this would not be possible if it were not for the real-time data they receive from the SNF.
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