Automated Care Management Reduces Readmissions & Saves Staff Time
Congestive Heart Failure (CHF) is putting patients, ACOs and health plans (particularly Medicare MA) under pressure. It is the highest costing ambulatory care sensitive condition (ACSC) in the US. One estimate suggests the total annual median cost of treating a heart failure patient is $24,383[1] with 65% of those costs ($15,879) attributable to hospitalization costs. And the number of Americans suffering from CHF is expected to increase by over 25% by 2030 to 8.5 million. CHF is disproportionally represented in low-income and the older population; over 7% of those in their mid-70’s to 80’s, suffer from CHF.
It is well established that Care Management can significantly improve life quality and reduce costs[2]. The problem is (human) Care Management is expensive; and given chronic staff shortages it’s hard to recruit and retain staff members.
What to do? Consider adding an AI Nurse that can augment your team and automate all routine Care Management. Florence is powered by evidence-based clinical protocols and AI; she collects clinical readings and tracks symptom exacerbation; she ensures medication adherence and health coaching – 24/7. Florence will notify your team based on trends or one-off events allowing your human team to step in when required.
Simply said, Florence takes care of all the routine work and enables the human team to engage with patients when it’s most valuable. Better for patients and more rewarding for your team.
66% Reduction in Readmissions
Is there clinical evidence? Yes. Over a decade’s worth; 200,000 patients, 25 million patient interactions across the US, UK and Australia delivering better clinical outcomes, enhanced efficiencies and lower costs. For CHF, that means 66% fewer emergency readmissions[3], 30% shorter average Length of Stay[4], fewer face-to-face appointments needed[5], and over 87% of patients reporting better understanding and management of their heart failure [6].
Described by clinicians as “almost the autopilot…a level of automation that makes the clinical team confident”, and the “best friend checking on me every day” by patients, Florence has enabled teams to “hit a very sweet spot using technology that is simplistic and makes patients feel cared for”.
Example Protocols
Protocol: Pre/Post Surgery (Hospital Managed)
- 90-day monitoring with focus on Symptom Checker: every 4 days for 60 days, then every 8 days.
- 90-day monitoring how patients are feeling relative to last few days; every 4 days for 60 days, then every 8 days.
- 1 lifestyle advice every 4 days (less salt, smoking, etc)
→ Outcome: 66% reduction in re-admissions, shorter Length of Stay, strong patient feedback, reduced depression, and anxiety[7]
Protocol: Simple Monitoring in Primary Care
- Send in weight daily with thresholds notification to nurse
- Reminders if no report within 2 hours
- Request to check Symptom Checker if weight movement
- If Symptom Checker = Red, Request patient to call Primary Care + Primary Care alerted
→ Outcome: Increased patient self-management, fewer face-to-face appointments needed, high patient satisfaction[8]
Protocol: Comprehensive Monitoring in Primary Care
- As above
- Send in Daily BP, Heart Rate, and Fluid Intake
- Comprehensive Reminders
→ Outcome: Increased patient self-management, sustained weight loss, sustained feeling of connection to care[9]
Automated Connection = Time and Money Saved.
Enrolling patients is easy. Florence eases the load on clinicians by being that “somebody there” for patients, providing vital support, monitoring medication adherence, symptoms, and vital signs, reassuring with feedback, alerting clinicians when necessary.
Increased patient engagement with Florence means fewer re-admissions; in that critical 30-day post discharge period, that is 70% fewer emergency readmissions than usual care,[10] substantial savings when readmission costs vary fivefold with comorbidity and can reach $25,879 if readmission is to a different hospital.[11]
It means improved patient wellbeing scores, enhancing health ownership and reducing reliance on face-to-face appointments, with time and cost benefits of self-efficacy extending beyond the end of protocols reflected in 42% lower hospital readmission at 6 months, and patients in primary care maintaining healthy weights.
Next Gen AI Informed by Lessons Learned
Patient feedback and lessons learned have been valuable in developing our next generation AI further enhancing our AI Nurse’s management of CHF patients.
- We have incorporated a simple mood score and more wellbeing resources to enhance focus on psychological wellbeing.
- Flo AI has facilitated even more human-like clinical conversations with patients with Florence able to interpret more patient responses and tap into a configurable Knowledge Base when patients request access to further information.
- Reminders have been incorporated into all protocols reflecting the value they represent.
- We have built in medication side effects reporting to reflect the greater focus on the effects of medication.
- However, while patients requested more flexibility in timings and symptom reporting we have yet to change Florence in this regard as good routine is important. On our roadmap, we are looking to enable Florence to cater for further patient preferences while ensuring consistency of data and highest clinical guidelines.
The future of CHF Care Management: AI reduces readmissions and saves staff time
The future may be closer than you think. With Florence you have effective Automated Care Management offering 24/7 support that reduces readmissions, and staff workload and improves quality metrics all at a fraction of the cost of human care. Easy for clinicians to implement, simple and accessible for CHF patients to use; one 90-year-old patient pleaded with his clinician “Please don’t take this away from me,” Florence does indeed hold the key.
See how you too can improve life quality for your CHF patients and reduce ACSC hospitalizations.
[1] (Urbich, et al., 2020)
[2] (AHRQ, 2014)
[3] UHNM Final Evaluation Report 2020
[4] (Wolters, 2018)
[5] See Patient Stories
[6] UHNM Final Evaluation Report 2020
[7] Case Study – Readmissions Down 66%
[8] See Patient Stories
[9] See Patient Stories
[10] UHNM Final Evaluation Report 2020
[11] (Urbich, et al., 2020)
References
AHRQ, 2014. Designing and Implementing Medicaid Disease and Care Management Programs, s.l.: s.n.
University Hospitals of North Midlands, 2020. Final Evaluation Report, s.l.: s.n.
Urbich, M., Globe, G., Paria, K. & Heisen, M., 2020. A Systematic Review of Medical Costs Associated with Heart Failure in the USA (2014–2020). Pharmacoeconomics.