Post-discharge plans get mobile boost

Goal is to reduce hospital readmissions
By Eric Wicklund
10:38 AM

It's often been said that telehealth programs offer benefits to healthcare providers in both rural and urban settings. Vree Health is proving that point with two new contracts – one in Big Sky Country, the other in the heavily populated Northeast.

The Merck subsidiary has announced contracts over the past two months to deploy its post-discharge care management programs for the Frontier Medicine Better Health Partnership, a Montana-based partnership encompassing all of the state's hospitals, and Griffin Hospital, a 160-bed acute care community hospital in Derby, Conn., serving more than 107,000 residents in Connecticut's Lower Naugatuck Valley.  Both projects will make use of Vree Health's TransitionAdvantage platform, which is designed to help patients hospitalized for heart attacks, heart failure or pneumonia to adhere to a hospital's recommended post-discharge care plan.

The goal of both projects is to reduce hospital readmissions – in particular, preventable readmissions within 30 days, for which the Centers for Medicare & Medicaid Services will penalize hospitals – by using telehealth tools to communicate with the patient at home.

[See also: Intermountain takes on readmissions.]

"Hospitals are being held accountable for something they haven't controlled or don't have the infrastructure to control," said Chris Ellis, director of marketing for the North Wales, Pa.-based company. "There are a lot of solutions out there that use technology, but one of the challenges is that the technology doesn't always have the right interface. They need the right (platform) to connect to patients."

Though targeting the same goals, both projects are decidedly different. In Connecticut, Griffin Hospital will use TransitionAdvantage to engage patients on a daily basis and coordinate with care providers.

“Helping patients transition from hospital to home is a major healthcare challenge that requires providing individual attention for each patient after they leave the hospital,” said Kathleen Martin, vice president for patient safety and care improvement at Griffin Hospital, in a press release. “As part of our commitment to being a leader in preventing hospital readmissions, Griffin Hospital is excited to be implementing TransitionAdvantage as part of our efforts to support patients during their post-hospital recovery.”

In Montana, meanwhile, FMBHP and Vree Health are working on a project, funded by a $10.5 million CMS Innovation Grant, to establish the TransitionAdvantage platform in communities throughout the state where discharged patients might be hundreds of miles from the hospital. Officials hope that all 48 of the state's critical access hospitals and rural health centers, serving 100,000 Medicare, Medicaid and Children's Health Insurance Program members, will be tied into the network by the third year of the three-year project.

"While transitional care is a challenge throughout the health system nationwide, rural communities like these in Montana have unique needs," said Denyse Traeder, FMBHP's director, in a press release. "We are excited to partner with the experts at Vree Health to develop new approaches to improve the transition from hospital to home in these areas."

[See also: Analytics take on fraud, readmissions and population health.]

According to Ellis, TransitionAdvantage, which was initiated roughly two years ago and is still in its beta stage (it's being used in an academic medical center and three hospitals), focuses not only on the technology platform, but on a call center staffed 24/7 by "transition liaisons," who maintain that link with patients as they move from the hospital back home. The technology platform links to the provider's electronic medical record and creates an electronic patient profile (EPP), which the transition liaisons use "to help the patient internalize behaviors that are positive and behaviors that are detrimental."

The liaisons "are highly trained to manage these patients," said Ellis. Using digital tools, he said, they serve as "daily health coaches, getting patients to self-commit" to health management goals. While having access to a 24/7 hotline, the patients are encouraged to complete daily "health checks" via phone, computer or mobile device.

"Rural patients discharged from tertiary care centers often head back (to a) home (that is) hundreds of miles away from the hospital," said Kyle Dolbow, Vree Health's president, in a press release discussing the FMBHP partnership. "TransitionAdvantage is designed to help improve patient handoff, post-discharge follow-up and medication management. Our high-touch service model helps patients improve their follow-up care and assists hospitals with reducing unnecessary readmissions. This can help with both care and costs in communities like those served by FMBHP."

As evidenced by the two recent contracts, the Vree Health program holds promise for healthcare providers in both rural and urban areas. Ellis said he expects the TransitionAdvantage platform to branch out to serve more patient communities, including those with chronic conditions.

"Really, any patient can benefit from this," he said.