Market Challenge

Today’s “revolving door syndrome” for at-risk patients is a serious and costly challenge. Some readmissions are unavoidable, but a major portion of return visits result from a fragmented approach to follow-up care. Discharged patients are often left to manage post-treatment on their own. They may be confused by discharge instructions, mix up their medications, or fail to get needed follow-up care.
In 2014, re-admissions cost the healthcare system $41.3 billion[1]
  • Payers absorb $17.5 billion in wasteful spending while patients face unnecessary medical risks and costs[2]
  • 75% of hospital readmissions are caused by preventable errors[3]
 

What We Do

HomeSTAR is an end-to-end post-acute offering that manages up to 90-day episodes of care, beginning prior to the patient’s discharge from the hospital, or for elective surgical cases, outreach begins prior to hospitalization. The program optimizes our home-based network, identifies the likely best site-of-care for the patient, manages length of stay (LOS) if a Skilled Nursing Facility (SNF) is appropriate, and reduces hospital readmissions. Our program also coordinates all of the services required for a patient to transition to their home faster and safer, via our network of home health, durable medical equipment and home infusion providers, all of whom are supported by our CareCentrix care coordination team.  
 
In addition, we go beyond traditional approaches to discharge planning and use real time, predictive analytics to identify the shortest path to success for the patient - to improve the predicted outcome. We work with the hospital discharge planner to facilitate the patient-specific recommended path of care.
 
Leveraging proprietary algorithms, which are based on over 100 million historical discharges, we are able to predict readmission risk, recommend the appropriate site-of-service for patients, and identify the optimal path of care for the patient being discharged. We help to identify the providers with best quality outcomes for the patient’s condition.
 
Once patients are at home, we use a proprietary technology platform called HomeBridgeSM to connect patients, caregivers, payers and agency partners to a single patient record and care coordination engine. This platform is designed to standardize care plans, communicate across the care team, integrate remote monitoring data, and report on patient status and outcomes. With HomeBridge, we can augment our traditional approach to in-market nurse staffing. To do so, we leverage technology, electronic service validations, and the ability to engage the patients directly in total care management. This leads to real-time reporting and patient management. In addition, we can identify non-medical gaps in care—including medication-related concerns, nutritional needs, transportation and caregiver support needs. 
 
Our solution, which has been deployed for nearly two million members, successfully reduced readmissions by over 38%, and saved a regional commercial plan in excess of $50M over the prior three years.
 

Benefits

CareCentrix’s HomeSTAR program can:
  • Reduce hospital readmissions and improve quality of care
  • Identify and facilitate appropriate services and resources post-discharge
  • Reduce utilization from both readmissions and across the entire healthcare system
  • Allow patients to return to their regular activities more quickly
 
[1] http://www.fiercehealthfinance.com/story/readmissions-lead-413b-additional-hospital-costs/2014-04-20
[2] Robert Wood Johnson Foundation, “The Revolving Door: A report on U.S. Hospital Readmissions” 2013. http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404178
[3] https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Draft-Measure-Specifications-for-Potentially-Preventable-Hospita-Readmission-Measures-for-PAC.pdf