Dovetail Health Prevents Re-Admissions in High-Risk Patients Using CareAnalyzer from DST Health Solutions

High-risk health plan members avoid readmission, stay at home 94 percent of the time

ORGANIZATIONAL PROFILE: Dovetail Health
Committed to the identification and support of patients at highest risk for adverse health outcomes, Needham, Mass.-based Dovetail Health offers member transition and complex care programs for health plans.  Dovetail Health relies onDST Health Solutions’ CareAnalyzer to refine the process of selecting the plan members who have the highest risk of multiple recurring hospitalizations, thus often being the most costly to the health plan.  Armed with that information, Dovetail Health has been able to produce positive care outcomes and better manage escalating health care costs. 

Dovetail Health’s work with Health New England based in Springfield, Mass. exemplifies this.  Starting in 2011, Dovetail began using CareAnalyzer for Health New England to identify their high-risk Medicare Advantage members for program enrollment; in addition, Dovetail implemented an innovative best practices approach to transition management.  Since the program’s inception, Dovetail Health reports that it has improved the health plan’s Medicare Advantage readmission rates by 36 percent.

BUSINESS CHALLENGE: Going After the High Costs of Readmission

The problem of readmissions is serious and pervasive.  In 2009, 16.1 percent of patients were readmitted within 30 days of discharge, according to a study of Medicare patients by The Dartmouth Institute for Health Policy & Clinical Practice.  

“High-risk patients represent an enormous financial exposure for health plans,” says Jeffrey Oberg, Director of Account Management, Dovetail Health.  “That’s why we work with health plans to identify patients with a high likelihood of returning to the hospital and then implement programs that stabilize and manage patients at home, keeping them out of the hospital.”   

Avoiding readmissions is also essential from a quality and patient safety perspective.  “The majority of patients in our program have significant medication reconciliation and medication adherence issues,” says Lara Terry, M.D., Medical Director, Dovetail Health.  “This is a population where investing in more services and highly personalized interventions makes sense for both the health plan and the member.”   

According to industry research, approximately two thirds of adverse events post-discharge are the result of medication related issues. This is one of the reasons Dovetail Health sends a pharmacist into members’ homes to perform medication reconciliation and optimization.  Further, patients get personalized chronic illness coaching to ensure they are knowledgeable about all aspects of their health management. 

Coordination with the patient’s primary care physician (PCP) is another key component of the program. The Dovetail Health transition team makes sure that a post-discharge appointment with the patient’s PCP is scheduled in a timely manner and helps the patient prepare a list of questions to discuss with his/her physician.  The Dovetail Health transition team continues to monitor the patient through ongoing telephonic management and will make referrals to additional programs and services as appropriate. 

Simply put, it’s very effective. By taking the best of the industry’s standard approaches to reducing readmissions and combining them with its own cost-effective home-visit based, pharmacist-led interventions, Dovetail Health can help health plans like Health New England better control its costs and deliver better care.

THE SOLUTION: The Strength of Proper Patient Analysis
In January 2011 Dovetail Health contracted with Health New England to support their newly established and growing 5,000-member Medicare Advantage plan, and to target patients at high risk for a hospital readmission, which can frequently cost between $6,000 and $10,000. 

Referrals for the Health New England Transitions Management program are generated by Health New England case managers. Prior to using DST, Dovetail clinicians noted that some of the patients referred were at a relatively low risk for readmission. Because of this, Dovetail Health created new thresholds for enrollment in its Transitions Management program by using DST’s CareAnalyzer,, a tool that incorporates Johns Hopkins’ ACG System to target high-risk patients and estimate resource use based on clinically relevant classifications.

Dovetail Health now receives electronic claims and enrollment files from Health New England  and, using DST’s CareAnalyzer, generates high risk member reports featuring ACG risk-adjusted member information, along with condition, cost and utilization data.  Using this report, Dovetail Health targets plan members for program enrollment using newly defined, unique criteria, including risk scores, prior admissions, number of medications, chronic conditions present and frailty indicators.  

Once Dovetail Health identifies Health New England’s highest-risk members, it uses the Member Clinical Profile, a one-page risk assessment available within CareAnalyzer for each member, to further assess the appropriateness of the program for the selected individual.  This review process also assists the transition team in developing an overall picture of the individual member’s health status, which is in-turn useful in determining interventions that might be applicable from a care plan perspective.
  
The tailored selection process is instrumental to the overall success of the program. “CareAnalyzer has provided us with a better means of identifying members who will benefit most from Dovetail’s care management services,” adds Dr. Terry. 

THE RESULTS: The Key to Keeping Patients at Home
The impact has been dramatic. Dovetail Health's Transition Management program has reduced readmission rates in Health New England's population by 36 percent, keeping their enrolled patients at home 94 percent of the time. By selecting the appropriate patients, DST's CareAnalyzer has had a measurable impact on the results. The referrals who were identified by CareAnalyzer to be a highest risk but who declined services had a markedly higher readmission rate than those who were referred and subsequently excluded for not meeting DST risk stratification criteria, 17.3 percent versus 11.4 percent, respectively. Further evidence of CareAnalyzer's success at accurate patient selection is the readmission rate of those referred and declined compared to the network overall, 17.3 percent versus 14.5 percent, respectively.

"Our industry leading transition management capabilities focus on one of the major root causes of re-hospitalization, namely poor medication reconciliation and poor medication adherence. In addition to clinical services, Dovetail provides support to concerned family members and caregivers," said Dr. Terry. "Dovetail has been able to improve the health of individual patients, lower hospital readmission rates and improve the health plan's bottom line."

"In an ideal scenario, we assume the selection of members into our program using criteria calculated by CareAnalyzer, and use ACGs as a method to control for underlying disease burden when assessing the effectiveness of our program," said Oberg.

"We have found Dovetail's business model combining the use of a pharmacist to go to the home and do onsite medication reconciliation with a tested proprietary methodology to assess those discharged patients most at risk for re-admission has worked incredibly well for us to better manage care transitions for a vulnerable and sick Medicare population," said Dr. Thomas Ebert, Vice President and Chief Medical Officer of Health New England.

ABOUT DOVETAIL HEALTH
With a sole focus on preventing readmissions among the highest risk patients, Dovetail Health is a leading provider of transitional care services. Combining unique in-home pharmacist care managers with comprehensive infrastructure and customized technology systems, Dovetail has delivered reductions in readmissions for its health plan, provider group and hospital partners. For more information, contact Dana McNally at dmcnally@dovetailhealth.com or visit www.dovetailhealth.com.

For more about DST Health Solutions, contact us at inforequests@dsthealthsolutions.com.