New Jersey-based Atlantic Well being System is collaborating with a startup firm referred to as Dimer Well being that’s utilizing expertise to fill the medical care gaps that exist for sufferers after a hospital discharge and cut back readmission charges. Steve Sheris, M.D., government vice chairman, chief doctor government 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 targets.
Hodge, a most cancers survivor herself, stated 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 gives distant proactive follow-ups and monitoring to scale back the possibilities of sufferers returning to the hospital.
“We are saying that similar 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 are able to take care of the affected person till we are able to hand them again off to their main care physician,” Hodge defined, “so that there is by no means a time when the affected person is not having their hand-held.”
In addition to working with medical teams in New Jersey, Hodge stated Dimer plans to increase into just a few extra states over the following couple of months.
Healthcare Innovation: Caroline, may you speak about your work with Atlantic Well being System?
Hodge: We have been working with doctor teams which can be inside Atlantic, and we have been seeing sufferers and rising inside totally different service traces, and we’ve had some actually nice outcomes, nice affected person tales. General, with the sufferers that we have seen there, we have been in a position to cut back readmissions over 65%, and the sufferers actually like 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?
Having the ability to use the expertise that we’ve to determine sufferers who’re most in danger to personalize the care plans for them, and determine the patterns who’re most certainly 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 after we ship these check-ins to them, and they’re going to reply and say, ‘, I really feel somewhat extra drained at the moment,’ or ‘I feel I might need a fever,’ we are able to dial up the depth of what we’re doing or dial it down based mostly on their response. So as a substitute of getting a stack of papers that is very diagnosis-based, we are able to 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 speak about why Atlantic Well being System was concerned with working with an organization resembling Dimer Well being?
Sheris: We need to put money into preserving well being and wellness upstream away from the extra conventional websites of care resembling hospitals, so remaining related with our sufferers always is one in every of our priorities. This technique is exclusive, as a result of most well being programs are nonetheless aligning themselves with the way in which healthcare is paid for on this nation. It is segmented, fragmented, episodic and transitional, slightly than repeatedly wrapped across the affected person. It is oriented to websites of care and never the individual getting the care.
We have been transitioning our personal healthcare supply system to stay related 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 weak 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 individuals are most weak. If they have been hospitalized and till they’ve gotten again to attach with their clinician, that is the place entrants like Dimer will 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 manner you described?
Sheris: Sure. We’re firmly dedicated to driving the business carriers and taking part in authorities applications that pay for outcomes-based reimbursement, holding 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 try to do is leverage these greatest outcomes, transfer them upstream within the care continuum, and make them steady and sturdy, investing in well being and wellness. We’re attempting to construct out at scale the capability to take care of folks in non-traditional websites of care. Expertise 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’ll work with them and collaborate with them, so long as the data 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 instantly 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 make sure that the data stays with the affected person. So we have been working with Dimer ensuring that our info programs 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 answerable for in our price contracts is just not useful to us. It truly may end up in duplication of care and confusion to the affected person, when you’ve got 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 answerable 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 perform as a medical follow and we invoice for our companies.
HCI: So if I am one in every 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 one in every of what we name our medical concierges, an administrative individual. When you have a medical query, you may get related to a PA, nurse practitioner or a doctor.
HCI: Might Atlantic be rewarded in its value-based care contracts if readmissions go down by this relationship with Dimer?
Sheris: Sure. We’re collaborating to supply the perfect take care of the affected person. We will not all be competing across the affected person. Now we have to be collaborating for the perfect affected person outcomes. For sufferers for whom we bear monetary threat on the entire value of care, sure, we profit from Dimer doing their job higher. We profit from different unbiased teams that follow 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 info to ship what the affected person wants, once they want it, wherever they want it.
HCI: Might this have an effect on the notion of whether or not folks must go to a post-acute care setting slightly than going residence after a hospital keep if you realize you have got extra high-touch care out there?
Sheris: Sure. Simply because folks go to a post-acute setting doesn’t suggest the care is related, 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 traces. We inform them that you should talk with us. We’re entrusting you with the care of a affected person that we bear moral, ethical and monetary accountability for. So please inform us what you are doing. Name us when one thing is just not proper, confirm the care pathway with us. So it is lots of conversations, and lots of blocking and tackling and pick-and-shovel work to truly join all of the totally different domains of care.
Hodge: To your query about that call of the place to discharge, we undoubtedly 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 hand-held and be seen inside 12 hours and possibly once more the following day, I might really feel extra comfy sending them residence. If I knew they have been going to have the ability to have affected person assessments adopted up on, I might need to ship them residence. We need to be a useful resource to assist facilitate these selections, too.