3 Steps for Lowering Readmissions Through Data Aggregation

“The chronic care management program is a way to be involved with a patient through data aggregation, vital signs, the evidence-based structure, and to give a clinician a report on a monthly basis to intervene and to improve the patient’s outcome in a proactive way,” he says. We encourage all of our facilities and clinicians to use the CCM outcome data at the Quality Assurance and Performance Improvement Committee (QAPI) meetings to drive performance improvement activities to improve the systems of care delivery, he says. “For example, the falls risk indicator and 12-month mortality indicators focus our clinicians on proactively reducing polypharmacy, increasing goals of care conversations from a facility perspective, but also allow us to drill down to the unique patient level.”

The data aggregation associated with a CCM program in the long-term care facilities supports the clinicians to make more informed decisions proactively while remaining patient-centric. Tracking those three pieces of data - antipsychotic use, fall risk and overall risk of readmissions - are yet another way that the CCM program can mitigate some of the challenges that SNFs face, thus creating ways for the facility to differentiate itself from others in the community. “Educating skilled nursing facilities about chronic care management and the patient population of the long-term care patients that it applies to is the first step SNFs can take to best change their chronic care management,” Swenson says. Chronic care management not only improves patient outcomes, but from a skilled facility perspective, chronic care management and data from it can be applied to the QAPI process as a proactive performance improvement.