Care Support for Recently Discharged Patients
We all want greater patient engagement, lower readmissions, and improved patient satisfaction. To achieve that, we need a careful combination of suitable technologies and human contact, a way that combines effective care teams with data exchange mechanism.
This is especially important for the vulnerable group of patients recently discharged from hospital.
“Transition Advantage is about people, process, and technology. It’s not pure technology solution,” said Kyle Dolbow, President of Vree Health, a company owned by Merck Pharmaceuticals, who propose what might answer the present needs of the industry.
The solution facilitates the care plan that’s provided by the hospital. An example could be a congestive heart failure patient about to be discharged.
The patient is enrolled in the service, and at discharge relevant data is pulled from the electronic medical records, and the patient is matched up with a person called the transition liaison. That transition liaison quickly carries out an interview with the patient to explain the program, conducts a motivational survey.
“What we want is to ground the interaction with the patient’s personal goals. That’s part of being patient-centric. We want to help the patient achieve their personal recovery goals,” Dolbow explained.
For our patient with congestive heart failure that might entail things like the liaison calling to check up on whether they take their medication as prescribed, what’s their weight, blood pressure, etc. “If the patient’s weight goes up by a certain percentage, our system can send an alert saying that you have a patient that may need an intervention. And that intervention can be triggered by our transition liaison calling and asking them about what they’ve been eating, so they can take a sense for their sodium intake,” said Dolbow. “If somebody needs to intervene, we work on the health coordination side. If their primary health physician has been involved in the program upon discharge, he can take over the care. All the stakeholders in that patient’s care need to be unified through the availability of data.”
The system is very patient-centric, offering flexibility to interact with people, but also with digital apps, depending on individual preference. “One of the things about the apps is that it’s trying to treat all people the same, and what we’re doing is trying to make it patient relevant, patient centric, and then it’s the care coordination piece that we have the right resource to understand what’s going on and if they need help,” Dolbow stressed, adding that many organizations Vree Health work with are adept at working with the systems within hospitals, but once the patient leaves, the connection is severed. “What the U.S. market place is struggling with is hospitals have become financially responsible for readmissions after someone has left the hospital, but they have a fragmented system of collaboration and a limited understanding what’s going on with that patient after they had left the institution. So part of the challenge is to understand what’s happening with the patient after they have left the hospital, and help the patient – and the patient’s care team – stay on the path to improved health.”
This is a service that isn’t directly tied to any of the pharma business. Although Vree Health are owned by Merck, they run their business firewalled from its mother company. Nevertheless, they stay true to the Merck’s legacy. “One of the principles that Merck pharmaceuticals was founded on was that if you take care of the patient, your business will thrive,” Dolbow said about the company taking a step back to realize that taking care of a patient is more than prescribing drugs, but it’s also about services that manage health outcomes.
Although for now the cooperation is set up between Vree Health, providers and patients, Dolbow hopes that with time and increased evidence base, payers will be involved as well. “In outcome-based care, the interest of payers providers and patients line up. Better outcomes are the most manageable cost, so when that happens, a service like ours should be embraced by providers, patients and payers.”
Currently, the cost of the service is covered by the hospital over the first 30 days.
What evidence is necessary? The goal of the program is to limit readmissions, and to make the necessary ones more manageable, by e.g. reducing admission through the ER. The other measure is patient satisfaction. “We’re an extension of the provider. Hospitals today are competing for patient loyalty or market share and patient satisfaction is a big deal for a hospital,” Dolbow admitted.
“When you look at outcomes focused health care, the interest of all parties are lined up, payers, providers, and of course, the patient” Dolbow elaborated. “What you will see in the future is new alliances to affect patient results. I think the way the new models will succeed is through ecosystems that are acting together to improve the care.”
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