New Jersey-based Atlantic Health System is collaborating with a startup called Dimer Health that is using technology to fill clinical care gaps that exist for patients after a hospital discharge and reduce readmission rates. Steve Sheris, MD, executive vice president, chief physician executive of New Jersey-based Atlantic Health System, and president of Atlantic Medical Group, and Dimer Health founder Caroline Hodge, MS, PA-C, MBA, recently spoke with Healthcare innovation about their objectives.
Hodge, a cancer survivor, said her personal experiences with gaps in post-discharge care, as well as her own career as a physician, inspired her to create a solution that would address gaps in post-discharge care. Dimer offers remote proactive tracking and monitoring to reduce the chances of patients returning to the hospital.
“We say that just as the patient goes from the emergency room to being admitted to the hospital, and the hospitalist cares for them in the hospital, the hospital can then hand them over to the transitionalist, and we can care for the patient until we can return them to their primary care physician,” Hodge explained, “so there is never a time when the patient is not holding hands.
In addition to working with clinical groups in New Jersey, Hodge said Dimer plans to expand to a few more states in the coming months.
Healthcare Innovation: Caroline, could you talk about your work with Atlantic Health System?
Hodge: We’ve been working with physician groups that are within Atlantic, seeing patients and growing within different service lines, and we’ve had really great results, great patient stories. Overall, with the patients we’ve seen there, we’ve been able to reduce readmissions by over 65% and the patients really love it. Our Net Promoter Score is incredibly high. It’s 95. We get comments from people saying: why hasn’t the attention always been like this?
Being able to use the technology that we have to identify patients who are most at risk to personalize care plans for them, and identify the patterns that are most likely to have escalations or decompensations in their condition, and then be able to act quickly. about it before they reach a certain threshold of exacerbation is how we have arrived at those results.
We really try to make it easier for them to access with this predictive and proactive outreach. So when we send them these logs and they respond and say, ‘You know, I’m feeling a little more tired today’ or ‘I think I might have a fever,’ we can increase the intensity of what we do. we are doing or reducing it based on your response. So instead of having a stack of paperwork that’s largely based on diagnosis, we can actually personalize that plan and adjust it hourly if necessary for that patient and keep them out of the hospital.
HCI: Dr. Sheris, could you explain why Atlantic Health System was interested in working with a company like Dimer Health?
Sheris: We want to invest in preserving health and well-being away from more traditional places of care, such as hospitals, so staying connected with our patients at all times is one of our priorities. This strategy is unique, because most health systems are still aligning with how health care is paid for in this country. It is segmented, fragmented, episodic and transitional, rather than continually involving the patient. It is oriented to the sites of care and not to the person receiving care.
We have been transitioning our own healthcare delivery system to stay connected to the patient outside of traditional care settings. Dimer Health can provide technology-based solutions at scale in those care settings where patients may be most vulnerable in care transitions.
Again, this country’s healthcare system, for the most part, still pays for transactional episodes, and does not pay for the connective tissue of care that keeps people healthy and well, that is, in the transitions where people are more vulnerable. If they have been hospitalized and until they have reconnected with their doctor, this is where participants like Dimer can help organizations like Atlantic Health System, because we haven’t built that infrastructure yet. We’re at an earlier stage in our own journey, because that’s not what the healthcare ecosystem has paid for.
HCI: But could solutions like this fit as the health system moves to more value-based care and gets paid less in the episodic way you described?
Sheris: Yes. We are strongly committed to boosting commercial carriers and participating in government programs that pay outcome-based reimbursement, keeping people healthy and well and avoiding high-cost care. Now we are six hospitals, with 400 care sites. We’re really good at delivering superior outcomes at those sites of care. What we’re trying to do is take advantage of those better outcomes, move them up the continuum of care and make them continuous and lasting, investing in health and well-being. We are trying to develop at scale the ability to care for people in non-traditional care settings. Technology gives us the opportunity to achieve that scale without bricks and mortar and without human capital, which is scarce. That’s why we’re looking for people who are committed to helping us on that journey, and we will work and collaborate with them, as long as the information they collect about patients remains in the ecosystem. We wire it up and it moves with the patient. It does not remain in the care silo where it was delivered.
HCI: What is the business model or relationship between a health system like Atlantic and Dimer? Does Dimer bill insurers directly or do they share the savings?
Sheris: There is no exchange of money between Dimer and Atlantic. Like any group practicing in our clinically integrated network, we want to ensure that the information stays with the patient. That’s why we’ve been working with Dimer making sure our information systems talk to each other. Otherwise it just becomes another fragmentation site that makes the problem worse. Care that we cannot see for the patients for whom we are responsible in our value contracts is not useful to us. In fact, it can result in duplication of care and confusion for the patient if there are multiple people observing the patient in their healthcare journey. That’s why, at this time, we are ensuring that communication channels are tight and automated, and that the primary care physician responsible for the patient’s longitudinal care in our value contracts is aware of every medical procedure and intervention. social, for example. That issue, that is spreading on behalf of the patients.
Hodge: We operate as a medical practice and bill for our services.
HCI: So if I’m one of these patients after discharge and I have a concern, I pick up the phone and call Dimer, who’s on the other end of the line? Are you a nurse or a personal assistant?
Hodge: You could talk to one of what we call our clinical concierges, an administrative person. If you have a clinical question, you will be connected to a personal assistant, nurse practitioner or doctor.
HCI: Could Atlantic be rewarded in its value-based care contracts if readmissions decrease because of this relationship with Dimer?
Sheris: Yes. We collaborate to offer the best patient care. Not all of us can compete around the patient. We have to collaborate to obtain the best results for patients. For patients for whom we assume the financial risk for the full cost of care, yes, we benefit from Dimer doing its job better. We benefit from other independent groups practicing in our clinically integrated network doing their work better. So it’s the same conversation. Dimer has demonstrated responsiveness, the ability to scale to use information to provide what the patient needs, when they need it, and where they need it.
HCI: Could this have an impact on the perception of whether people need to go to a post-acute care setting instead of returning home after a hospital stay if they know they have more high-contact care available?
Sheris: Yes. Just because people go to a post-acute setting doesn’t mean care is connected, right? It’s about connection. Therefore, it is simply another form of post-acute care. We are also dedicating efforts with those facility-based providers along the same lines. We tell them that you need to contact us. We entrust you with the care of a patient for whom we assume ethical, moral and financial responsibility. So please tell us what you are doing. Call us when something is not right, verify the care route with us. So, it’s a lot of conversations and a lot of blocking and tackling and picking and shoveling to really connect all the different realms of care.
Hodge: To your question about that decision of where to discharge, we definitely see ourselves as a tool in that toolbox, as one more option. A hospitalist might say that if I knew this patient would be held and seen within 12 hours and perhaps again the next day, I would feel more comfortable sending him home. If I knew they were going to be able to follow up on patients’ tests, I would like to send them home. We also want to be a resource to help facilitate those decisions.
