New Jersey-based Atlantic Well being System is collaborating with a startup firm known as Dimer Well being that’s utilizing expertise to fill the medical care gaps that exist for sufferers after a hospital discharge and scale 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., not too long ago spoke with Healthcare Innovation about their objectives.
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 affords distant proactive follow-ups and monitoring to scale back the probabilities 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 will take care of 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 stated Dimer plans to increase into just a few extra states over the subsequent couple of months.
Healthcare Innovation: Caroline, might 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 strains, and now we have 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 scale back readmissions over 65%, and the sufferers actually like it. Our Web 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 expertise that now we have to establish sufferers who’re most in danger to personalize the care plans for them, and establish the patterns who’re most probably going to have escalations or decompensation of their situation, after which have the ability to shortly 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’ll reply and say, ‘You already know, I really feel just a little extra drained in the present day,’ or ‘I believe I may need a fever,’ we will dial up the depth of what we’re doing or dial it down based mostly 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 maintain them out of the hospital.
HCI: Dr. Sheris, might you speak about why Atlantic Well being System was curious about working with an organization akin to Dimer Well being?
Sheris: We wish to put money into preserving well being and wellness upstream away from the extra conventional websites of care akin to hospitals, so remaining related 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 way in which healthcare is paid for on this nation. It is segmented, fragmented, episodic and transitional, fairly 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 normal 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 individuals wholesome and nicely, so within the transitions the place persons 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 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 might 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 packages that pay for outcomes-based reimbursement, preserving individuals wholesome and nicely 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 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 individuals in non-traditional websites of care. Expertise affords us the chance to attain that scale with out bricks and mortar and with out human capital, which is in restricted provide. That is why we’re searching 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 straight or do they share financial savings?
Sheris: There’s not an alternate of cash between Dimer and Atlantic. Like all group that practices in our clinically built-in community, we wish to ensure that the knowledge stays with the affected person. So we have been working with Dimer ensuring that our info methods talk with one another. In any other case, it simply turns into one other website of fragmentation that worsens the issue. Care that we will not see for sufferers that we’re liable for in our price contracts just isn’t useful to us. It really can lead to duplication of care and confusion to the affected person, in case you have a number of individuals wanting 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 providers.
HCI: So if I am considered one of these post-discharge sufferers, and I’ve a priority and choose up the cellphone 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 individual. You probably have a medical query, you will 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 very best take care of the affected person. We will not all be competing across the affected person. We have now to be collaborating for the very best affected person outcomes. For sufferers for whom we bear monetary danger on the entire 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 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 individuals have to go to a post-acute care setting fairly than going dwelling after a hospital keep if you understand you’ve got extra high-touch care out there?
Sheris: Sure. Simply because individuals go to a post-acute setting does not imply 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 strains. We inform them that it’s essential to 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 just isn’t proper, confirm the care pathway with us. So it is a whole lot of conversations, and a whole lot 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 device 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 subsequent day, I’d really feel extra snug sending them dwelling. If I knew they had been going to have the ability to have affected person assessments adopted up on, I would wish to ship them dwelling. We wish to be a useful resource to assist facilitate these selections, too.
