Transition to Home was launched before the COVID-19 crisis hit, and it has gone through a few iterations since. Signify began doing on-the-ground work in the Midwest specifically, but once the virus took hold, it became a virtually focused solution. Signify works with the Centers for Medicare & Medicaid Services (CMS) on its Bundled Payments for Care Improvement (BPCI) Initiative, which is a Center for Medicare & Medicaid Innovation (CMMI) creation. Broadly, the BPCI initiative consists of organizations entering into payment arrangements that measure financial and performance accountability for Medicare beneficiaries’ episodes of care. Signify first identifies beneficiaries that are a part of the bundled payment program. Afterwards, they follow patients once they are discharged from acute care, then reach out to those patients to find out how they’re doing at home — and what challenges they are facing there.
Its Transition to Home clients thus far include Ardent Health Services, Beaumont Health, Cape Fear Valley Health and Premier Health, among others. The Dallas-based Signify arranged the program’s pilot with that research and understanding in mind, coupled with its existing capabilities, which include advanced analytics and technology.
“We wanted to bring that evidence basis together in a scalable, sustainable fashion to members of the BPCI program, who have transitioned to home and really want to avoid rehospitalization,” Rothman said. “That’s sort of the nidus of the program.” “We know that rehospitalizations in this country have historically occurred far too often — upwards of 20% to 30% — for Medicare beneficiaries,” Dr. Marc Rothman, Signify’s CMO, told Home Health Care News “And this is something we’ve known for a solid 20 years. And over that time, the evidence basis for what allows people to stay at home safely and avoid rehospitalizations has been nicely built out by leaders in medicine and research.”
While the program is virtual now, that is not how Rothman nor Signify views it permanently. As things move forward, the hope is that more in-person visits can be conducted to improve the model further. When that happens, home-based care providers will likely have the chance to help reduce the unwanted hospital visits. “We’re seeing a lot of interest in rehospitalization-reduction strategies across the board, whether that’s with at-risk providers, hospital systems or physician groups,” Rothman said. “Health insurance organizations are interested in this as well because they’re looking at the total cost of care. And for them, readmissions are also undesirable. And the patients, of course, are the ones who want the service the most because the least satisfying outcome for a patient who goes home after being hospitalized is to be hospitalized again.”
It’s a solution that has become coveted among health care providers and others, especially during the public health emergency. Those challenges could include ones relating to social determinants of health or clinical issues, and Signify then aims to fill those gaps in care in the home. To do so, social care coordinators, social workers, nurses, nurse practitioners, physicians and pharmacists are all enlisted, depending on the issues.
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