Northwestern Medicine Reduces Readmissions, Earns $1 Million Net Swing in Reimbursements

The Challenge

Three years ago, Northwestern Medicine’s hospital in Crystal Lake, Illinois, was paying penalties averaging $300,000 a year to the Center for Medicare and Medicaid Services. One challenge: preventing its bundled payment patients from making a U-turn back into the hospital.

The Chicago-based hospital (formerly Centegra Health System) wanted a solution to help its case managers improve communication with post-acute providers and steer patients to the best—and most cost-effective—care.

The push to better coordinate care came eight months after the hospital joined Medicare’s Bundled Payment for Care Improvement program. It enrolled 425 high-care patients: those who had congestive heart failure or had a knee or hip replacement.

Solution

The hospital partnered with Dina, a HIPAA-compliant cloud and mobile-based care coordination platform, to connect high-performing post-acute, home and community-based providers. The connected platform also includes AI capabilities to analyze patient data and suggest evidence-based interventions. 

It also wanted to reduce the communication gaps that often occur when multiple providers are involved with patient care post-discharge. The goals: lower readmissions, reduce uncompensated care due to unnecessary ER visits, and speed up patient transitions to post-acute and home.

Northwestern’s key partners are connected on the platform so there is visibility into patients throughout their care journey. These include:

Skilled Nursing/In-Patient Rehab

• The Springs Rehabilitation
• Crystal Pines Rehabilitation
• Fair Oaks Health Care Center
• Wauconda Care
• Hearthstone Manor

Home Health/Hospice

• Bowes In Home Care
• Assure Home Healthcare
• Great Lakes Caring
• Ultra Care Home Health
• One Home Health
• JourneyCare

PCP/Clinic

• Centegra Physician Care
• Centegra Cardiovascular and Thoracic Center
• Telemedico Physicians

Home Care/Private Duty

• Homewatch Caregivers
• Assisting Hands

“I think the biggest hurdle we had was not knowing what happened to our patients when they left our doors,” said Astrid Larsen, director of care coordination. “We were hands-off unless there was a problem.”

Results

After using Dina for 18 months:

• Readmission rates for chronic heart patients dropped by 12%
• Readmission rates dropped 29% overall
• The length of stay in a skilled nursing facility for knee and hip replacement patients dropped by 4.6 days
• The number of knee and hip replacement patients who spent time at an inpatient rehabilitation facility dropped from 5% to zero
• Results added up to $700,000 in bundled payment reimbursements, a $1 million net swing from the prior year

“Now we can foster communication and be proactive with patients before they showed up in the hospital or ER,” said Larsen. “We can intervene much quicker if there was an issue, often preventing second or third hospital visits.”