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Value-based care analytics and technology company Signify Health is launching a solution called Transition to Home in more than 50 hospitals to provide Medicare patients with clinical and social care support as they transition from the hospital to the home, the company announced this week.
The solution is designed to complement existing post-discharge care coordination strategies at hospitals, health systems, clinically-integrated networks (CINs) and accountable care organizations.
Through virtual and telephonic clinical and social care coordination, Signify is emphasizing a holistic clinical model that supports Medicare patients for 90 days following discharge from an acute care facility. The company then collaborates with patients and their care teams in an attempt to improve quality of care and outcomes.
WHAT’S THE IMPACT?
Potentially avoidable hospital readmissions cost Medicare approximately $17 billion per year with hundreds of thousands of patients affected, according to the Kaiser Family Foundation. Post-discharge barriers to recovery are responsible for many of these readmissions and encompass a broad range of issues, such as social determinant of health gaps, multiple comorbidities, medication mismanagement and poor care plan adherence.
An analysis of readmission results for 800,000 episodes of care managed by Signify Health under Medicare’s value-based bundled payment program shows that nearly 44% of all readmissions occur more than 30 days following discharge from the hospital.
To address the risk of readmission during this critical phase, Signify’s solution provides evidence-based clinical and social care coordination services to patients during the 90 days following discharge. The services offered include risk stratification, patient education, a social needs and behavioral health assessment, medication review, care plan reminders, PCP and specialist follow-up facilitation, coordination with acute care clinicians and escalation and triage care pathways.
The services are performed by an interdisciplinary care team of clinical and social care coordinators, pharmacists, nurses and physicians, who maintain a regular cadence of contact with patients and providers to identify and address individual needs.
The care team coordinates care with the patient’s primary care provider. Care coordinators typically identify between two and four social needs (such as food insecurity and lack of access to transportation) per patient and are able to address more than 50% of those needs, said Signify.
The program is currently supporting patients in 10 states.
THE LARGER TREND
Signify Health recently teamed up with major insurer Humana and the Alamo Area Community Network to support Humana Medicare Advantage members in San Antonio through AACN’s community resources and by connecting those in need with health-related social services such as food, transportation, housing and financial assistance.
The AACN is a partnership of more than 40 organizations, with a number programs and services geared toward effectively impacting social determinants of health for San Antonio residents.
The partnership also includes Signify Health’s Social Care Coordinators, who will provide outreach to Humana members to help them resolve their unmet needs.
ON THE RECORD
“As large health systems and physician groups assume more risk, they are looking to better address those clinical and social gaps that exist outside the acute care setting, but that can have a significant impact on the health outcomes of their patients,” said Signify Health CEO Kyle Armbrester.
“We are delighted to activate our extensive capabilities of engaging patients in and around the home for our provider partners participating in episodes and other value-based programs. Facilitating a timely transition to the home and extending our partners’ reach beyond the hospital setting will enhance patient care experience, achieve better outcomes and improve financial performance.”
“Signify Health’s evidence-based approach for our Transition to Home solution focuses on key drivers of unnecessary rehospitalizations,” said Dr. Marc Rothman, chief medical officer of Signify Health. “Our clinical and social care professionals are trained to address patients’ needs regardless of their risk level, ensuring that provider care teams can focus on the highest-need cases. Ultimately, this offering was built to deliver on the most important metric of success: healthier, happier patients and empowered clinicians.”