Need Statement
Provide timely, predictable, and anticipated reconciled individualized discharge follow-up plans that move with patients longitudinally over time, in the transition of care between hospital and home.
Rough Cut Need:
Transition of Care Actionable Data (ToCADA) with Deep Learning (DL) to predict real-time admissions and reconcile discharge plans in chronic care for radiology.
During outpatient/clinical discharge process patient’s to home, or subacute nursing homes, caregivers or relatives get a complex printed instructions (drug regimens are only followed at 40% at best, and are root-case of 70% of non-reconciled drugs regimens detected in re-hospitalized preventable visits. These revisits are detected in 20% of Medicare readmissions within 30 days, for an estimated $15 billion in annual Medicare spending).
Other weak points of peak vulnerability with respect to patient health needs points of peak vulnerability with respect to patient health needs include lack of 48 discharged summaries availability, forgotten flag verbal recommendations when close to time of discharge, and lack of continuum of care indicators to be predicted in the community after hospital stay. These drawbacks of transition of care not only are focused under the poor patient/caregiver to clinician (sometime nurse) personal communication, but also in the perfect timing to schedule primary care visit (addressing the correct time for first visit can lower rates of follow-up visits in some pathologies that had a higher risk of 30-day readmission)
In fact, Medicare beneficiaries readmitted to the hospital within 30 days of discharge, only 50 percent had been evaluated by a physician in the ambulatory arena with a had a ten-fold- greater risk for readmission. The lack of transition of care continuity of flow limits the possibility to anticipate possible clinical scenarios that may manifest over the weeks after discharge, along with recommendations for adjustments to the treatment plan that in many times are performed retrospectively. It is known that a drug’s low adherence, and misinterpretations in follow-up care instructional care plan can lead to poor outcomes, high antibiotic resistance rates, and many preventable revisits with unnecessary costs especially in chronic diseases.
From an economic perspective, inadequate transitions in care can be quite costly. Under the Medicare Hospital Readmissions Reductions Program (HRRP) established in the Affordable Care Act, financial penalties will be imposed on hospitals with excess readmissions. The bottom line is that there are many assess patient risk readmission tools and risk stratification tools found highly effective to assess patient’s retrospectively over the fragmentation in the transition from hospital to home, but there are not a hand offs solution between hospital, ambulatory predictor of care to be focused on anticipating the likely points of peak vulnerability with respect to patient health needs upon discharge.
Section A: Sizing the Total Market
How many prospective patients would be impacted by your idea?
The size of transition care in the US, it is about 34.4 billion dollar. In US the healthcare spent is almost 18% of GDP which is one of the highest in the world and out of the entire healthcare spent, a good 12 percent is actually spent on post acute care or post hospitalisations. Within this 12% again a good 7 % is spent on transition care which is largely a combination of in-house rehabilitation facility and skilled nursing facilities, so market opportunity is quite large, since the transition care market size is a derivative of the overall healthcare span ($2,4 billion dollar).
The United States is estimated to have a population of 328,863,150 as of October 24, 2018 As of 2017, people are distributed by age 55-64 years: 12.91% and 65 years and over: 15.63%, for a total of 28%, which are the main of population that use Transition of Care. Among hospitalized patients 65 or older, 21 percent are discharged to a long term care or other institution. Approximately 25 percent of Medicare skilled nursing facility (SNF) residents are readmitted to the hospital. Individuals with chronic conditions—a number expected to reach 125 million in the U.S. by 2020—may see up to 16 physicians in one year. Between 41.9 and 70 percent of Medicare patients admitted to the hospital for care in 2003 received services from an average of 10 or more physicians during their stay.
On average, how much does the existing/current treatment/solution cost?
The main three solutions are the following:
The Care Transitions Intervention (CTI), is primarily a transitions self management model that provides coaching, skills and tools to help patient’s and caregivers assert a more active role during transitions. This intervention is low-cost, low intensity and has been shown to produce a sustained effect reducing hospital readmissions significantly for five months following the one-month intervention. It is also expected to result in nearly $300,000 in savings for the care of 350 chronically ill adults over 12 months. (The program has been tested with patients that are 65 years or older with poor self-health ratings, multiple chronic conditions, and a history of recent hospitalizations.
One randomized study of the program indicated that the annual total intervention cost was $115,856 ($982 per patient). The study also concluded that reductions in utilization of health services led to mean annual cost savings, over and above the costs of the intervention, of $5,000 per patient.)
The Transitional Care Model (TCM), developed at the University of Pennsylvania, establishes a multidisciplinary team that is led by a master’s prepared transitional care nurse (TCN) to treat chronically ill high risk older patients before, during and after discharge from the hospital. This model has proven to decrease preventable hospital readmissions, improve health outcomes and reduce health care costs. A randomized evaluation of the program indicated that the total annual intervention cost was $1,743 per patient, producing a savings, above and beyond the cost of the intervention, of $1,364 per patient.)
Geriatric Resources for Assessment and Care of Elders (GRACE) is a physician/practice-based care coordination model. GRACE is conducted for a long-term/indefinite amount of time and requires a nurse practitioner and social worker.
GRACE has been tested for low-income individuals aged 65 years or older in primary care, including a group at high risk of hospitalization (as determined by the probability of repeated admission risk screen). A randomized study indicated the total annual intervention costs for high- risk patients to be $315,040 ($1,432 per patient). The study concluded the intervention to be cost-neutral for high-risk patients due to reductions in hospital costs
What are the growth trends in the treatment/solution/process (how much larger is the need likely to get)?
We need only to look at the high prevalence of hospital readmissions and medical errors to see the costs of care transitions and their adverse economic implications to the U.S. healthcare system:
Medication errors harm an estimated 1.5 million people each year in the United States, costing the nation at least $3.5 billion annually. One study found that, on discharge from the hospital, 30% of patients have at least one medication discrepancy. According to another study, one in five U.S. patients discharged to their home from the hospital experienced an adverse event within three weeks of discharge. Sixty percent were medication related and could have been avoided.
On average, 19.6% of Medicare fee-for-service beneficiaries who have been discharged from the hospital were readmitted within 30 days and 34% were readmitted within 90 days have been rising at a rate of 5% per year. Other have shown that hospital readmissions within 30 days accounted for $15 billion of Medicare spending.
If I use the same parallel on healthcare spent, we are talking about 34.4 billion dollars market size as far as transition care is concerned at the current rate of spending (7%) but given the current focus on healthcare there is a likelihood that the spending may increase and since the transition care market size is a derivative of the overall healthcare span. (For 2015-25, health spending is projected to grow at an average rate of 5.8 percent per year (4.8 percent on a per capita basis).)
What evidence is there confirming or conflicting with the answers to the above? (if you have found data or evidence related to your answers in any of the resources above, point that out)
The National Transitions of Care Coalition (NTOCC) and its multidisciplinary team of health care leaders are committed to improving the quality of transitions of care. National Health Expenditure Projections 2015-2025. Center for Technology and Aging (Technologies for Improving Post-Acute Care Transitions),Position Paper September 2010. Medicare Post-Acute Care Transformation Act of 2014
Section B: Market Segmentation
- How is the market typically segmented?
Acute/Post-Acute Care Transition: he process by which a patient moves from hospital to home or other settings.
Hospital-to-home care transition: Which patients with complex care needs and family caregivers receive specific tools and work with a “Transitions Coach” to learn self-management skills that will ensure their needs are met during the transition from hospital to home.
Home follow- up by advanced practice nurses (APNs) to older adults at high risk: A comprehensive discharge planning follow- up by advanced practice nurses (APNs) to older adults at high risk for poor outcomes.
- Are these typically patient- or provider-based segments?
Acute/Post-Acute Care Transition: patient-based
Hospital-to-Home Care transitions: patient-based
Home follow- up by advanced practice nurses (APNs): provider-based segments
- What is the size of each segment (numbers and revenue)?
There are overlapping size of market as current segmentation in transition of Care is complex due to age range and socioeconomic factors.
Acute/Post-Acute Care Transition:
Market: The program has been tested with patients that are 65 years or older with poor self-health ratings, multiple chronic conditions, and a history of recent hospitalizations.
Revenue: the annual total intervention cost was $115,856 ($982 per patient). The study also concluded that reductions in utilization of health services led to mean annual cost savings, over and above the costs of the intervention, of $5,000 per patient.
Hospital-to-Home Care transitions:
Market: The program has been tested with patients that are 65 years or older with poor self-health ratings, multiple chronic conditions, and a history of recent hospitalizations.
Revenue: The annual total intervention cost was $115,856 ($982 per patient). The study also concluded that reductions in utilization of health services led to mean annual cost savings, over and above the costs of the intervention, of $5,000 per patient.
Home follow- up by advanced practice nurses (APNs):
Market:
itE has been tested for low-income individuals aged 65 years or older in primary care, including a group at high risk of hospitalization (as determined by the probability of repeated admission risk screen).
Revenue: the total annual intervention costs for high- risk patients to be $315,040 ($1,432 per patient). The study concluded the intervention to be cost-neutral for high-risk patients due to reductions in hospital costs.
- What are the strengths and weaknesses, or the benefits and problems, with the typical segmentation?
Current segmentation is based on age ranges and WHO per disease codes. Although the healthcare population is almost as diverse as the population at large, there have only been very limited attempts to segment this population based on experienced needs fulfilment. The World Health Organization’s International Classification of Diseases is the best-known classification system, but this groups diseases rather than persons, and is based on objective clinical judgements, not on personally felt needs.
This generate a lack of adjustments in treatments options and affect savings. Healthcare organizations or insurance companies for instance may screen their older adults, using this shortlist, in order to analyse their own local or regional elderly population’s distribution over the segments. This may serve as input for aligning the experienced unfulfilled needs of their older adults and the practice’s supplies. For example,older adults in the segment ‘Difficulties in psychosocial coping’ often did not report to have received psychosocial care from e.g., a psychotherapist or social worker.
The strengths are that this segmentation divides the market into patient with relative (medium) power to determine patient at high risk or readmissions. It could thus be useful to be able to predict and reconcile drug regimens and treatment options based on human behavior on a totally different person-centred segmentation to be used on a policy level to develop a new portfolio of care and services in an ambulatory care centre for transition of care.
- For the product or service under consideration, would an alternative segmentation be valuable? What recommendations would you have regarding this?
First, knowing an older adult’s segment offers care providers contextual information, which may be helpful to interpret the symptoms the person expresses and to discuss the implications of a diagnosis with the older adult. More importantly, the segment-based information offers a starting-point for providing more person-centred care, for starting to talk about unfilled needs instead of symptoms and diseases. On the other hand, the elderly segments which are characterized by more complex interrelations between experienced difficulties in the person’s functioning might benefit from active case management. Future research could focus on the required level of sensitivity and speci city in order to develop more person-centred care.
Section C: Market Competition
In the box below, please answer the following five questions:
Who and/or what are the companies/alternatives?
There are companies currently in the healthcare transition of care patient market, but there are no companies that can reuse clinical and patient daily use data to predict onto a patient’s information the best personal tailored care.
Most of the companies are centered in on aspect of the transition. For instance patientping.com allow to obtain real-time, actionable data on your patients with providers coordinating care through real-time notifications. Others center in drug reconciliation like cpstelepharmacy.com that allow pharmacists to be included in transitions of care to improve outcomes and lower readmissions.
No competitors can predict actionable data in a platform to redefine care in person-centred segmentation on an individual client level.
What are the competitor products or services?
Current companies are in the field of coordinated services during and following the hospitalization by a healthcare professional with special preparation (nurse), by improving bidirectional communication silos.
How are these companies, products, and services different from each other?
Current companies differ from each other in spoce of care. Some are focused in cardiac or diabetic poscare, while other prefer to focused their advanced practice nurses (APNs) in chronically ill patient’s that need more assistance.
What part of the market does each competitor serve? In other words, what is their market share?
Each competitor serves as a provider of the whole market for transition of care but with difference for instance:
Complex care needs and family caregivers receive specific tools:
-Providing continuity of care across settings, and supporting the patient in developing and maintaining a personal health record, and coaching/role playing with patients to ask the right questions.
-Home follow- up by advanced practice nurses (APNs):
-In-hospital assessment and Physician-nurse collaboration across episodes of acute care.
For those products not currently in the market, where are they in their development (in other words, what stage)? When are they expected to receive approval? How much will each treatment cost?
The good news is that come companies have completed the whitelist process to get access to the HL7v2 and FHIR APIs and deep learning cloud to predict models for poscare. The great news is that, as part of this, some companies will enter in the arena to build and iterate through Alpha, Beta, and into General Availability code critical to shaping the product going forward.
Still Documentation is very much a work in progress, but Alpha access is by invitation only. The artificial intelligence transition of care will affect the cost, by reducing price per intervention and rising positive earnings to the system. Up to Date unknown.
III. Basic Stakeholder Assessment Template
Key Stakeholder 1:
- Name or title of the stakeholder individual or group
Hospitals
- Description of the stakeholder role
Location where the start the transition as early as hospital admission. Should be assessed for patient risk of readmission using an evidence-based risk assessment tool as early as possible to avoid penalties by HRRP.
- Explain why you believe this is a “key” stakeholder. In other words why do you think they have high power and high concern about your need/idea?
Should be assessed for patient risk of readmission using an evidence-based risk assessment tool as early as possible to prevent readmissions, that not only generates costs, but will prevent HRRP penalties for hospital readmissions limits at a lower costs of entrance, with early intervention to predict next visit, ensure clinician information transfer, and drug reconciliation not only at discharge but during the complete follow-up plan that moves with patients longitudinally over time.
Key Stakeholder 2:
In the box below, answer the three questions about the first stakeholder:
Name or title of the stakeholder individual or group
Insurance Companies
Description of the stakeholder role
Pay for the cost of the treatment, and preventable revisits.
Explain why you believe this is a “key” stakeholder. In other words why do you think they have high power and high concern about your need/idea?
Potential to reduce overall costs per patient discharge costs related with unexisting or inadequate follow-up plans. The U.S. insurance system often fails to meet the needs of patients during transitions because care is rushed and responsibility is fragmented, with little communication across care settings and multiple providers. These failures create serious patient safety, quality of care, and health outcome concerns to insurance companies.
THE CHALLENGE:
For many procedures and treatment pathways (e.g., a total knee replacement), there are distinct points along an episode of care that a patient progresses through. However, at each point, there is tremendous physician and staff variability in practice leading to significant inefficiency and high costs.
Bundled payments are an alternative payment structure, which reimburse healthcare providers, on the basis of expected costs for standardized clinically-defined episodes of care. Bundled payments aim to reduce healthcare costs for specific episodes of care by encouraging providers to redesign care delivery through: (1) reducing variability; (2) increasing efficiency; and (3) improving outcomes.
OUR SOLUTION:
Surgeons from our Orthopedic and Neurosurgery departments developed evidence-based clinical care pathways for patients undergoing a total knee replacement or spinal surgery from pre-operative consultations through post-operative rehabilitation and follow up appointments.
RESULTS TO DATE:
We are currently piloting our knee replacement care pathway at Brigham and Women’s Hospital. Physician-level metrics such as OR time, hospital length of stay, and discharge disposition will be monitored and reported regularly as will quality and safety metrics such as patient readmission and complication rates. We expect to have results soon.
Integrated Care Management Program (iCMP)
THE CHALLENGE:
For patients with complex medical conditions, navigating the healthcare system can be a challenging and frustrating experience. At BWH we are focused on better coordinating care for patients with complex medical conditions through our Integrated Care Management Program (iCMP).
