A trusted Masonic resource in the heart of Michigan, Masonic Pathways is a not-for-profit life plan retirement community offering independent and assisted living, short-stay rehabilitation, skilled nursing, and memory care support
No stranger to the importance of reducing rehospitalizations
Currently Masonic Pathways participates as one of 11 post-acute care providers within the Mid-Michigan Health Performance Network, which is
managed by Signify Health, one of the largest Bundled Payment for Care Improvement Advance conveners in the United States. As a network member,
Masonic Pathways receives a monthly quality scorecard rating and training on how to decrease overall length of stay and reduce rehospitalization rates.
As post-acute care organizations grapple with a multitude of strategic challenges, those conveners and acute care hospital systems continue to put the pressure on post-acute care providers to reduce overall rehospitalizations within their communities. However, without an affordable technological solution to assist in managing residents, the clinical team continued to “dig into” resident charts in the hope of finding trends or clues that would help improve rehospitalization rates.
Finding a way to move the needle
Given these challenges and the desire to strengthen relationships with not only Mid-Michigan Health Performance Network, but also with Signify Health, Masonic Pathways realized they needed a technological solution. In late 2020, they implemented SAIVA Healthcare’s machine-learning tool that taps into a facility’s EHR patient data.
Essentially, the artificial intelligence technology does the work of pouring through the resident’s chart to find trends and behaviors that predict when they are at risk of decline and potentially being rehospitalized. The output is a daily report that lists the residents at highest risk of rehospitalization and their most pertinent clinical data from the EHR. The report is simply emailed to the head nurse each morning and is used to prioritize and focus resident care to prevent negative outcomes.
A dramatic reduction in hospital readmissions
During the initial three-month implementation period, Masonic Pathways cut new resident rehospitalizations in half—from 20% to 10.5%. For an organization that had already experienced some success with improving rehospitalization rates, these results were exciting. In addition to the improved clinical quality achieved, such a reduction in hospital readmissions also had a dramatic effect on census and, ultimately, revenue.
One of the key factors that contributed to the successful adoption of the SAIVA technology was its simplicity. Within a few short weeks, the technology was in place and the clinical team was receiving daily reports in their email every morning. The report has both a Summary and Patient Detail tabs. The Summary Tab helps to quickly identify new patients who are now at risk, as well as get an update from the previous day. For patients identified as at risk, the Patient Detail Tab provides risk indicators such as active diagnoses and conditions, vitals, key labs, and alerts. The daily reports also offer the additional benefit of strengthening the overall clinical acumen of the team.
After gaining team input during the interdisciplinary clinical meetings every day, residents are triaged for a plan of action. Updates recorded in their medical records throughout the day then inform the SAIVA technology for the next round of risk reports
Solidifying preferred partner status
The success realized with SAIVA technology has also solidified Masonic Pathways position with both the Mid-Michigan Health Performance Network and Signify Health for its commitment to improving resident care. The monthly quality scorecard rating continued to increase, demonstrating ongoing and sustainable improvements.