App uses Data and Clinical Decision Support to Decrease Hospital Readmissions

Coordination and continuity of care during transitions between care settings are priorities for all healthcare stakeholders—so much so that efforts to bolster continuity were included in the “meaningful use” EHR Incentive Program. The Long Term and Post-Acute Care Health IT Summit session “Using Mobile Technology to Empower $10/Hour Lay Caregivers to Prevent $10,000 Readmissions” highlighted new data collection applications targeted at reducing hospital readmissions.

Presenter Andrey Ostrovsky, MD, is the co-founder of Care At Hand, a mobile and web-based application designed to be used by non-skilled community caregivers—individuals without any formal medical training—working for Area Agencies on Aging (AAAs). The app, used by community caregivers, features a survey used to assess and track a patients’ medical issues, as well as provide clinical decision support to caregivers using it.

The app prompts caregivers to ask elderly patients questions about their health, with about 40 percent of the questions centered around upstream health determinants, Ostrovsky explains. Patients can be monitored by AAA workers over a period of weeks or months to the point where all the data that’s collected can be used to alert the caregiver to problems and prompt them to take action.

“It sends an alert to a supervising nurse care coordinator and that nurse care coordinator is able to use that alert to decide how to handle this,” Ostrovsky said. The nurse can then determine whether she should schedule an appointment with the patient’s primary care provider, or arrange to have a registered nurse visit the patient for a skilled assessment, all of which preclude a hospital admission.

“Certainly we have some really simple, but quite meaningful, decision support built into that process. So the nurse can have her clinical hunch. But if she doesn’t know the patient, she may not see the bigger picture,” Ostrovsky says.

Click here to read a Health Information Management Systems Society (HIMSS) case study of Care at Hand about how it enabled AAA to decrease 30-day hospital readmissions by 39.6 percent for its six referring hospitals.


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