Christiana Care uses tech to coordinate postdischarge care

Female doctor talking to male patient in hospital bed
Christiana Care Health System has embraced health IT in its discharge protocols. (Getty/monkeybusinessimages)

Christiana Care Health System has embraced health IT in its discharge protocols, and the system is seeing the payoff in reduced readmission rates.

Christiana received a $10 million grant from the Center for Medicare and Medicaid Innovation in 2012 to build its CareLink CareNow infrastructure, which coordinates care for close to 75,000 Medicare beneficiaries beyond discharge, according to an article from Hospitals & Health Networks. Through the program, the system has seen a 30% reduction in 90-day readmission rates.

For instance, a patient who was guardian of her three grandchildren needed to have transportation in place and the children enrolled in school before Christiana could fully connect with her about her healthcare.

“We realized that had to be in place before we could engage the patient herself,” Tabassum Salam, M.D., head of the CareLink project, told H&HN. “So we are that glue—that continuity for our patients.”

The CareLink system is connected to the Delaware Health Information Network and also includes an analytics system that scores patients based on their medical history, the number of medications they’re currently prescribed and how many comorbidities, if any, they have. Patients with higher scores are given the most attention in the program, according to the article.

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But many patients need help understanding the complexities of postdischarge care. Tech solutions can streamline the process and make it easier to schedule followup care and monitor patients from home. Mobile apps can allow nurse to remotely monitor vital signs and track other crucial information.

Research has also found that standardized discharge protocols improve patient satisfaction and allow for a more efficient process.