Key Takeaways

This interview has been edited for length and clarity.

Preventable and unnecessary readmissions cause a variety of issues in healthcare. They consume resources from both patients and organizations. Often, they divert the attention of care teams away from top-of-license care. And they can even lead to more confusion and inadvertent harm for individuals.

With successful transitions of care crucial to preventing extra trips to the hospital, how does the industry begin to understand the root causes that lead to gaps during times of change?

In this episode of the Memora Health Care Delivery Podcast, our guest Kurt Martin, FACHE, Senior Director of Operations at MedStar Health, discusses healthcare challenges aging populations face, why moving toward patient-centered care is imperative for healing care gaps, and how his organization approaches proving impact.

Aging populations face unique healthcare obstacles

About one in five patients experience an adverse event during transitions of care. However, as Martin explains, aging populations are especially susceptible. Why? Because of their frequent use of healthcare services. 

Martin explains, “I think we in healthcare tend to be overwhelmed by where to start with some of these problems. And I think this [aging adults] is a great population to start with because they're experiencing all of it. And they're our heaviest users of the health system right now.”

What makes things more complicated is that aging adults are usually quite unaccustomed to more routine and robust encounters with providers until they experience a significant episode of care. He says, “If we really think about what an older adult goes through, first off, oftentimes they’re healthy. They’ve turned 65. They’re now on Medicare or Medicaid, and starting to learn what those benefits are. And then they have their first heart attack, first stroke, first incident. And now they’ve started needing to utilize a healthcare system that we aren't trained on using.”

“​​From 18 to 44, you're only really using the healthcare system for emergencies and your annual primary care visit. Now you're having to navigate specialists. You're having to navigate skilled nursing and home care and all of these other aspects of healthcare that you've never needed before,” he adds.

Innovation must focus on creating more patient-centered, connected care

To put it simply, the U.S. healthcare system is frustrating for patients. In fact, a recent Ipsos poll discovered 61% of Americans consider it “a hassle” and 63% say that navigating care is “stressful.” Ultimately, a fragmented model built around hospital needs instead of patient needs is to blame. In response, many stakeholders across the industry have called for more patient-centric care that is easier to understand.

The key ingredient to making care more patient-centric, Martin argues, lies in buttoning up transitions of care. He remarks, “We tend to see changes in the quality of care as we transition from skilled nursing to home or hospital to skilled nursing — all these places where we have the opportunity to drop the ball.”

But it’s not just important to heal gaps in provider communication and coordination. Martin proposes it’s imperative to understand patients’ difficulties when navigating other aspects of life that might contribute to their health statuses. He explains, “I remember one story of this older adult couple that was aging in place … Our social worker went in and one day found them sitting comfortably in their home, but heating it by keeping the oven on because they couldn't figure out how to pay the electric bill. It wasn't that they couldn't pay the electric bill. They couldn't navigate the system to pay the electric bill … It's not something I need a doctor doing. It was something that for the health of that patient needed to be done.”

Memora Health’s intelligent care enablement platform is developed to actively collect important SDOH and health literacy data from patients so that care teams and associated social workers have the information they need to make effective interventions.

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Proving ROI for alternative payment models continues to be challenging

Talk of emerging alternative payment models isn’t new. The shift from fee-for-service to value-based care (VBC) has been long-heralded as a critical step for advancing outcomes and healing care gaps. But as VBC arrangements expand throughout the U.S. healthcare system, how are providers able to prove their financial returns?

There isn’t one clear answer. And the reason why has a lot to do with the very goals of VBC — to align payment with quality of care. Martin expands, “I think that's the challenge of all the value-based models, right? Because so much of the financial ROI is on the back end. It's, ‘Prove that the patient wouldn't have used the system as much or that your intervention kept them from experiencing a hospital event.’ I think that's what will always be a challenge in these value-based systems.”

Martin explains the way MedStar Health measures ROI, remarking, “When we look at the level of complexity based on all the different diagnosis codes and compare that against a similar Medicare population, we know our patients use the hospital 50% less, they use the ED 45% less … So we know our patients use the hospital less, and we know that's where the majority of healthcare spending is. It's in the hospital, it's in the subacute rehabilitation. So if we can keep the patients happy, healthy, and at home where they want to be, where we want them to be, everybody benefits.”

As providers across the nation grapple with a constantly evolving healthcare landscape, understanding the root causes of adverse events that land people back in the hospital will be crucial. By analyzing transitions of care among aging populations, concentrating efforts on advancing patient-centered care, and understanding the impact of alternative models of care, organizations can promote more seamless experiences and, ultimately, positive health outcomes.