A patient with congestive heart failure (CHF), who was recently discharged from a nursing home, was experiencing shortness of breath especially at night. He triggered an alert to a triage nurse specialist who called him and then sent a registered nurse (RN) to his home to assess his health. The RN determined that the man’s lungs were clear but learned that his salt intake was very high which led to water retention that backed up into his lungs. She provided a diet plan and instructions to weigh himself every day and report in on any weight gains. She also checked in with him daily.
The patient is enrolled in a post-discharge program of Centers Health Care, a post-acute care provider that operates nursing homes in New York and New Jersey. Centers developed a patient engagement platform to coordinate and monitor the scope of care for high-risk patients upon discharge from a Centers’ nursing home, including PCP and specialist visits and needed community services like transportation and home delivered
The program was launched in Centers’ six Bronx nursing homes in 2018 as an Innovation Fund pilot supported by Bronx Partners for Healthy Communities (BPHC), the DSRIP Performing Provider System of SBH. The 13-month pilot diverted patients, like the man with CHF, from hospital readmissions resulting in $1.1 million savings in care costs and 85% of enrolled patients wanting the pilot to continue.
Centers has since expanded this program to each of their nursing homes in downstate New York and is looking to employ it at all of its facilities in the future. As the program continues to grow so will the platform’s capabilities including remote patient monitoring and telehealth.
“Technology offers new capabilities and innovations that allow us to fill care gaps and deliver the right kind of care,” says Irene Kaufmann, BPHC Executive Director. “The key is that these new models remain patient-focused with the providers driving the care.”
Centers’ platform, called CentersLink, serves as a live hub of information sharing and patient care coordination for the first 30 days after a patient is discharged from a Centers’ facility.
The platform allows Centers’ care coordinators to provide updates to the primary care physician (PCP) from other facilities, send appointment reminders to patients, confirm that the visit took place, and ensure that patient data is exchanged through the care process.
Care coordinators also speak with patients daily to check in and determine if additional care and services may be needed – whether it’s a visit to a PCP, home care, or transportation to a doctor’s office. Patients can contact Centers through CentersLink 24/7 with any concerns or questions.
Cipora Moskowitz, Director of Partner Engagement at Centers, attributes this patient-centered approach to the success of CentersLink. “We wanted to see if we could utilize technology to stay engaged with our patients longer after they left our facilities,” she says. “The pilot with BPHC was our launching pad and taught us that we can do that and engage with our patients on many different levels. Technology is the tool that has allowed us to do better for our patients.”