AHRQ’s Care Coordination Work Leads to Better Outcomes, Lower Costs for Massachusetts Agency on Aging

Elder Services of the Merrimack Valley (ESMV), a Lawrence, Massachusetts-based Area Agency on Aging that provides care transition services to local hospitals, has reworked its care transition model thanks to a mobile technology product called Care at Hand. That product, which was inspired by AHRQ's Care Coordination Measures Atlas, has helped ESMV reduce its 30-day readmissions rate for Medicare patients by 39.6 percent over six months.   

"Care at Hand allows us to deliver high-quality care at a lower cost," says Lori O'Connor, R.N., director of nursing and community health programs at ESMV. As a participant in the Centers for Medicare & Medicaid Services' (CMS) Community-based Care Transitions Program, ESMV leaders knew they had to supplement their teams of non-clinically trained health coaches—licensed social workers or bachelor's-educated employees trained in motivational interviewing—with more direct clinical support to improve care transitions from the hospital and reduce readmissions, as called for under the CMS care transitions program. "We're trying to come up with a new way to provide care with nurse oversight," Ms. O'Connor explains.

ESMV looked to Care at Hand to do so. Since implementing it in July 2013, ESMV has had clinical oversight of its health coaches and educators when they are with patients in their homes or in skilled nursing facilities. "We couldn't put a nurse in everybody's house," says Ms. O'Connor. "Not every patient needs a nurse, but some do." Because health coaches are not trained to perform the same level of assessment as a nurse, some symptoms may have gone undetected by health coaches that would be caught by a nurse.

Care at Hand, which can be accessed on a handheld device, prompts health coaches with simple surveys to fill out during each encounter with a patient. In plain language, survey questions are automatically adapted to pertain to each patient's health condition. "Survey results go immediately to the nurse care manager," Ms. O'Connor explains. Texts and email alerts also are sent instantly to the care manager if results meet a critical threshold determined by the product's algorithm. Care at Hand allows clinicians to have their "eyes and ears on the ground in a low-cost way," she adds.  

Developed by Andrey Ostrovsky, M.D., chief executive officer of Care at Hand and a pediatric resident at Children's Hospital Boston and Boston Medical Center, Care at Hand is informed by the evidence compiled by AHRQ's Care Coordination Measures Atlas. In 2007, AHRQ set out to remedy a lack of measures—specifically on the structures, processes, and intermediate outcomes—in the then-emerging field of care coordination. The effort culminated in December 2010 with the release of the Care Coordination Measures Atlas, which was designed to help evaluators identify appropriate measures for assessing care coordination interventions in research studies and demonstration projects, particularly those measures focusing on care coordination in ambulatory care.

The Care Coordination Measures Atlas was updated in 2014. It now includes additional information about new approaches to the measurement of care coordination in primary care settings and profiles of 80 measures of care coordination.

"The Atlas gave me a mental model for thinking about the multiple moving parts of care delivery outside of the hospital setting," says Dr. Ostrovsky, "The Atlas provides a menu of care coordination models and measurement tools that allowed me to operationalize my vision of empowering lower-cost workers to practice to the top of their training or license."

In using the Atlas to develop Care at Hand, Dr. Ostrovsky designed a product that allows health coaches to better detect patient decline and tie in nursing oversight more tightly at a lower cost. It also provides users with better and more precise data about their own patient populations.

 "Nurse care managers are now able to receive real-time information about health decline and perform immediate triage while the health coach is still in the patient's home," says Dr. Ostrovsky. "We can tell our customers what is going wrong and how to fix it."

 "The current claims data that is delivered to us by CMS does not allow us to do the ‘Plan, Do, Study, Act' rapid cycle process improvement," says Ms. Connor, adding that it has time lags and lacks information on which patients have been discharged to nursing facilities. "Care at Hand has allowed us to better track our patients, readmission rates, and patients going to nursing facilities." This helps ESMV better manage patients, identify patients at highest risk of readmission, and better match coaches to patients.

It is also helping improve the patient's experience of care, helping ESMV strive toward Triple Aim principles—improved health, enhanced patient experience, and lower costs—espoused by the Institute for Healthcare Improvement. 

When first implementing Care at Hand in July 2013, ESMV enrolled only those patients who had three or more hospital admissions during the previous year. Due to its initial success, the program was expanded to include all Community-based Care Transitions Program patients after just four months of implementation.

After six months, ESMV had the following results:

• Hospital readmissions dropped by 39.6 percent, from 24 percent to 14 percent.
• There was a net savings to Medicare of $567,071 during the six months.
• A total of 492 alerts were issued: 98 percent led to a follow-up phone call, 9 percent resulted in a nurse visit, and 3 percent led to a physician visit.

The cost savings from reduced readmissions far outweighed the rise in costs of care coordination and technology.

AHRQ's Care Coordination Measures Atlas was the impetus for these improvements in patient care. According to Dr. Ostrovsky, "We keep deriving inspiration from the Atlas."

To read more about Care at Hand, go to http://careathand.com.

The Care Coordination Measures Atlas can be viewed at http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/index.html.