New Jersey-based Atlantic Well being System is collaborating with a startup firm referred to as Dimer Well being that’s utilizing know-how to fill the medical care gaps that exist for sufferers after a hospital discharge and cut back readmission charges. Steve Sheris, M.D., govt vice chairman, chief doctor govt of New Jersey-based Atlantic Well being System and president of Atlantic Medical Group, and Dimer Well being founder Caroline Hodge, M.S., PA-C, M.B.A., just lately spoke with Healthcare Innovation about their objectives.
Hodge, a most cancers survivor herself, mentioned her private experiences with post-discharge care gaps in addition to her personal profession as a clinician impressed her to create an answer addressing gaps in post-discharge care. Dimer provides distant proactive follow-ups and monitoring to scale back the probabilities of sufferers returning to the hospital.
“We are saying that identical to the affected person goes from the emergency room to being admitted to the hospital, and the hospitalist takes care of you within the hospital, the hospital can then hand off to the transitionist, and we will look after the affected person till we will hand them again off to their major care physician,” Hodge defined, “so that there is by no means a time when the affected person is not having their handheld.”
In addition to working with medical teams in New Jersey, Hodge mentioned Dimer plans to broaden into just a few extra states over the following couple of months.
Healthcare Innovation: Caroline, may you discuss your work with Atlantic Well being System?
Hodge: We have been working with doctor teams which might be inside Atlantic, and we have been seeing sufferers and rising inside totally different service strains, and we’ve had some actually nice outcomes, nice affected person tales. Total, with the sufferers that we have seen there, we have been in a position to cut back readmissions over 65%, and the sufferers actually adore it. Our Internet Promoter Rating is extremely excessive. It is 95. We get feedback from individuals who say, why hasn’t care all the time been like this?
With the ability to use the know-how that we’ve to establish sufferers who’re most in danger to personalize the care plans for them, and establish the patterns who’re more than likely going to have escalations or decompensation of their situation, after which have the ability to rapidly act upon it earlier than they attain a sure threshold of exacerbation is how we have gotten to these outcomes.
We actually attempt to make entry straightforward for them with this predictive, proactive outreach. So once we ship these check-ins to them, and they’ll reply and say, ‘You recognize, I really feel just a little extra drained at present,’ or ‘I feel I might need a fever,’ we will dial up the depth of what we’re doing or dial it down primarily based on their response. So as an alternative of getting a stack of papers that is very diagnosis-based, we will actually customise that plan and regulate it hourly if wanted for that affected person and preserve them out of the hospital.
HCI: Dr. Sheris, may you discuss why Atlantic Well being System was focused on working with an organization reminiscent of Dimer Well being?
Sheris: We need to put money into preserving well being and wellness upstream away from the extra conventional websites of care reminiscent of hospitals, so remaining linked with our sufferers always is considered one of our priorities. This technique is exclusive, as a result of most well being methods are nonetheless aligning themselves with the best way healthcare is paid for on this nation. It is segmented, fragmented, episodic and transitional, somewhat than repeatedly wrapped across the affected person. It is oriented to websites of care and never the particular person getting the care.
We have been transitioning our personal healthcare supply system to stay linked with the affected person outdoors the standard websites of care. Dimer Well being can present technology-based options at scale in these domains of care the place sufferers could also be most susceptible within the transitions of care.
Once more, the healthcare system on this nation, for essentially the most half, nonetheless pays for episodes of transactions, and it would not pay for the connective tissue of care that retains folks wholesome and effectively, so within the transitions the place persons are most susceptible. If they have been hospitalized and till they’ve gotten again to attach with their clinician, that is the place entrants like Dimer may also help organizations like Atlantic Well being System, as a result of we haven’t constructed that infrastructure but. We’re earlier in our personal journey, as a result of that is not what the healthcare ecosystem has paid for.
HCI: However may options like this slot in because the well being system transitions to extra value-based care and receives a commission much less within the episodic means you described?
Sheris: Sure. We’re firmly dedicated to driving the industrial carriers and taking part in authorities applications that pay for outcomes-based reimbursement, preserving folks wholesome and effectively and avoiding high-cost care. We’re now six hospitals, with 400 websites of care. We’re actually good at delivering superior outcomes in these websites of care. What we are attempting to do is leverage these finest outcomes, transfer them upstream within the care continuum, and make them steady and sturdy, investing in well being and wellness. We’re making an attempt to construct out at scale the capability to look after folks in non-traditional websites of care. Know-how affords us the chance to realize that scale with out bricks and mortar and with out human capital, which is in restricted provide. That is why we’re on the lookout for people who find themselves dedicated to serving to us on that journey, and we are going to work with them and collaborate with them, so long as the knowledge that they collect about sufferers stays within the ecosystem. We hardwire that, and it strikes with the affected person. It would not keep within the silo of care the place it was delivered.
HCI: What’s the enterprise mannequin or relationship between a well being system like Atlantic and Dimer. Does Dimer invoice the insurers immediately or do they share financial savings?
Sheris: There’s not an trade of cash between Dimer and Atlantic. Like every group that practices in our clinically built-in community, we need to be certain the knowledge stays with the affected person. So we have been working with Dimer ensuring that our data methods talk with one another. In any other case, it simply turns into one other web site of fragmentation that worsens the issue. Care that we will not see for sufferers that we’re liable for in our price contracts isn’t useful to us. It really may end up in duplication of care and confusion to the affected person, if in case you have a number of folks trying in on the affected person of their healthcare journey. So proper now, we’re ensuring that the communication channels are tight and automatic, and ensuring that the first care clinician who’s liable for the longitudinal care of the affected person in our price contracts is conscious of each medical intervention and social intervention, for that matter, that is being prolonged on behalf of the sufferers.
Hodge: We operate as a medical apply and we invoice for our companies.
HCI: So if I am considered one of these post-discharge sufferers, and I’ve a priority and decide up the telephone and name Dimer, who’s on the opposite finish? Is it a nurse or a PA?
Hodge: You may speak to considered one of what we name our medical concierges, an administrative particular person. If in case you have a medical query, you may get linked to a PA, nurse practitioner or a doctor.
HCI: May Atlantic be rewarded in its value-based care contracts if readmissions go down by means of this relationship with Dimer?
Sheris: Sure. We’re collaborating to supply the most effective look after the affected person. We will not all be competing across the affected person. We have now to be collaborating for the most effective affected person outcomes. For sufferers for whom we bear monetary threat on the overall value of care, sure, we profit from Dimer doing their job higher. We profit from different impartial teams that apply in our clinically built-in community doing their job higher. So it is the identical dialog. Dimer has proven a capability to be responsive, to have the ability to scale up to make use of data to ship what the affected person wants, after they want it, wherever they want it.
HCI: May this have an effect on the notion of whether or not folks have to go to a post-acute care setting somewhat than going dwelling after a hospital keep if you might have extra high-touch care obtainable?
Sheris: Sure. Simply because folks go to a post-acute setting doesn’t suggest the care is linked, proper? It is concerning the connection. So it is simply one other type of post-acute care. We’re additionally expending efforts with these facility-based suppliers alongside the identical strains. We inform them that it’s essential talk with us. We’re entrusting you with the care of a affected person that we bear moral, ethical and monetary duty for. So please inform us what you are doing. Name us when one thing isn’t proper, confirm the care pathway with us. So it is plenty of conversations, and plenty of blocking and tackling and pick-and-shovel work to really join all of the totally different domains of care.
Hodge: To your query about that call of the place to discharge, we positively see ourselves as a instrument in that toolbox, as another choice. A hospitalist may say if I knew this affected person was going to have their handheld and be seen inside 12 hours and perhaps once more the following day, I’d really feel extra comfy sending them dwelling. If I knew they have been going to have the ability to have affected person exams adopted up on, I would need to ship them dwelling. We need to be a useful resource to assist facilitate these selections, too.
