Mobile care management program helps ACO slash readmissions

A California accountable care organization (ACO) is seeing lower number of hospital readmissions of high-risk patients thanks to a two-year mobile care management project.

The Meritage Accountable Care Organization recently announced that its Bay Area-wide Medicare patient readmission rate is now at 10.2 percent, well below the 17.5 percent national average as of 2013 for Medicare patients.

"As an ACO, we have extra incentive to lower readmissions by managing the quality of the care we deliver throughout the entire continuum," Andrea Kmetz, R.N., director of care management and quality assurance at Meritage ACO, says in the announcement.  

The program combines a hybrid model of care with a cloud-based mobile navigation network to offer a secure, patient-focused collaboration among providers in various care settings. Meritage ACO's care providers, which are located across 2,600 miles, can interact and collaborate on patient transition plans and post-discharge follow-up efforts using the information-sharing platform and mobile devices including tablets and smartphones.

For example, the system can provide patients and caregivers a checklist to ensure all the needed post-discharge actions are taken by the appropriate team member.

The platform makes it easy for clinicians and nurse care managers situated at all of our participating facilities to communicate securely about the patients they treat while keeping all care team members informed and updated on new developments, Kmetz says. She notes it would be impossible to share critical clinical data in a timely and efficient approach via traditional phone calls, pages, faxes or email.

Johns Hopkins Medicine in Baltimore also is tapping tablets as part of its new "harms monitor" system, in which patients and families are provided the portable computing devices for tracking care issues and gaining insight on care operations.

The Meritage ACO program focuses on older adult patients at a high risk for readmission, with most suffering from complex chronic conditions and some dealing with psychosocial needs that negatively impact their ability to manage personal healthcare. A recent study reported mobile tools can help boost adherence in global chronic disease management, which leads to improved health and more cost-effective care.

For more information:
- read the announcement