Montana project seeks safer transitions
April 24, 2013 in Medical Technology
A new project between Frontier Medicine Better Health Partnership, a collaborative working to standardize operations across Big Sky Country’s hospitals, and Vree Health, which develops technology aimed at improving readmissions, aims to improve care transitions and reduce readmission rates for patients in rural areas.
Over the coming months, officials from FMBHP, a data-driven effort to drive efficiencies across Montana’s hospitals, including tertiary care centers, critical access hospitals, and rural health clinics, say Merck subsidiary Vree Health will help in the development of innovative processes for transitioning patients from hospital to home within at least 10 Montana communities that will be pilots to inform later programs.
“While transitional care is a challenge throughout the health system nationwide, rural communities like these in Montana have unique needs,” said Denyse Traeder, director of FMBHP, in a press statement. “We are excited to partner with the experts at Vree Health to develop new approaches to improve the transition from hospital to home in these areas.”
Funded by a $10.5 million Center for Medicare Medicaid Services Innovation Grant, the FMBHP project will implement TransitionAdvantage, Vree Health’s post-discharge service, within the FMBHP-served community in an effort to improve post-hospital patient care and hospital efficiency in rural Montana.
TransitionAdvantage is tailored to help patients who have been hospitalized for heart attacks, heart failure or pneumonia adhere to their hospital’s recommended post-discharge care plans, and to help hospitals and other healthcare providers identify potential health issues in these patients before those issues become urgent and potentially costly.
The platform integrates with a hospital’s electronic medical records system to provide data accessibility and connectivity to the patient’s care team, including hospital staff, primary care physicians, patients and family caregivers.
Vree Health’s transition liaisons – daily health coaches – are then assigned to each patient before he or she leaves the hospital to conduct daily phone calls, log key parameters and transfer health issues to the respective healthcare provider.
FMBHP members and Vree Health will begin identifying implementation strategies immediately, officials say, and by the third year of the project, FMBHP anticipates that 48 critical access hospitals and rural health centers, serving 100,000 beneficiaries of Medicare, Medicaid and the Children’s Health Insurance Program, will be included in the network and eligible for TransitionAdvantage.
“Rural patients discharged from tertiary care centers often head back home, hundreds of miles away from the hospital,” said Kyle Dolbow, president of Vree Health, in a statement. “TransitionAdvantage is designed to help improve patient handoff, post-discharge follow-up and medication management. This can help with both care and costs in communities like those served by FMBHP.”