BAYADA Reduces Readmissions By 75% with Real-Time Care Coordination

Challenge

Like many home health organizations, BAYADA is continuously striving to improve patient health while:

• Enhancing the overall care experience,
• Improving the cost of care, and
• Reducing the need for readmissions, which can contribute significantly to higher costs.

One area BAYADA wanted to manage more effectively was Congestive Heart Failure (CHF). According to research published by the American Academy of Family Physicians, CHF is the most common discharge diagnosis in patients older than 65 years old. The incidence of heart failure in patients older than 80 years is 9%. Unfortunately, the prevalence of heart failure continues to rise and has resulted in an annual expenditure of $10 billion for diagnosis and treatment.

In addition, research shows that approximately 30% to 40% of patients with heart failure are readmitted within six months of hospitalization. Studies have concluded that readmissions for heart failure could be prevented in at least 40% of cases if patients were monitored for early warning signs and sent to the appropriate level of care.

BAYADA sought to implement a new model that would allow caregivers to monitor their patients as they moved throughout the care continuum on their journey home. The organization needed a solution to provide instant communication and track transitions across the care team from the hospital to the patient’s home. Goals were to reduce hospital readmissions, improve patient safety and enhance overall patient satisfaction.

“Fast communication across organizational boundaries is critical,” said Eric Thul, president, Bayada Medicaid Personal Care, Bayada Home Health Care. “Sometimes six hours can be the difference between a hospitalization event or having someone stay safely at home.”

Solution

To successfully implement its new model for CHF patients, BAYADA provided care management and care coordination services for all patients as they transitioned from the hospital into the new CHF program.

During the process, BAYADA leveraged Dina to connect care managers with staff members from the hospital, home health, primary care and cardiology practices where they shared patients.

Throughout the 30-60-90 day BPCI programs, BAYADA’s care team could securely share information about patient visits that occurred in the hospital, during home visits, or during phone calls – all by communicating through the Dina mobile app. Dina’s HIPAA-compliant platform allows caregivers to communicate in real time, which helps all team members stay current with patient developments.

“Being able to connect all the different parties together on the same platform and have that collaboration with the physician, nurse practitioner, nurse, PT’s, OT’s so they can easily access all of the client’s information…that’s beautiful,” said Amie Martinelli, director of home health, BAYADA Home Health Care. “Things don’t get lost in translation either.”

Dina also helps BAYADA’s partners throughout the network to apply best practices at the point of care. Using proprietary AI technology, Dina can detect patterns in patient data that suggests a certain health event is on the horizon. The app then notifies caregivers of the issue and suggests actionable interventions to take before conditions worsen.

“What Dina allowed us to do was encourage and prompt conversations through artificial intelligence prompts around the needs of our clients,” said Thul. “At the end of the day, healthcare and home care is a service industry. All we are, are people communicating with other people.”

Results

Upon implementing Dina, members of BAYADA’s connected care team were able to collaborate instantly. Care providers were able to intervene in real-time, preventing complications that would typically lead to a hospitalization or preventable readmission.

Through the three-month Dina trial, BAYADA proved the coordinated care from hospital to home can make a meaningful impact on readmissions risk. After going live with Dina, BAYADA was able to reduce congestive heart failure readmissions to 10.7%. When the trial was halted to observe the impact on readmissions, the rate returned to 40%.

With the help of Dina, BAYADA was also able to improve:

• Clinical team engagement
• Clinician knowledge sharing
• Intervention management
• Partner affinity
• Patient transitions

“Partnering with Dina has allowed us to proactively care for seniors in the Philadelphia market,” said David Baiada, chief operating officer, BAYADA Home Health Care. “With Dina, we’re able to identify clients who require timely interventions and empower them to live independently in their homes and communities.”

Heart Failure in the U.S.:

• CHF is the leading cause of hospitalization for patients over 65
• Annual costs associated with heart failure is $32 billion
• Average length of stay is nine days per patient
• 61% of CHF patients are readmitted within the first 15 days
• 50% of patients have a five-year mortality rate