mobile technology

The historical progression of bundled payments from acute care to post-acute care and the growing recognition of the value of HCBS create an interesting opportunity for sustainably integrating medical services with other (LTSS). Building on past lessons from efforts to incorporate community-based LTSS into traditional medical care models, such as care transitions, may help to inform successful future strategies to enable bundles to more efficiently achieve the Triple Aim.

Hospital readmissions are a large source of wasteful healthcare spending, and current care transition models are too expensive to be sustainable. One way to circumvent cost-prohibitive care transition programs is complement nurse-staffed care transition programs with those staffed by less expensive nonmedical workers. A major barrier to utilizing nonmedical workers is determining the appropriate time to escalate care to a clinician with a wider scope of practice.

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an AAA in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Review the AHRQ study that gave the program a moderate evidence rating for improving outcomes, decreasing cost of care.