Three years ago, Northwestern Medicine’s hospital in Crystal Lake, Illinois, was paying penalties averaging $300,000 a year to the Center for Medicare and Medicaid Services. One challenge: preventing its bundled payment patients from making a U-turn back into the hospital. 

“I think the biggest hurdle we had was not knowing what happened to our patients when they left our doors,” says Astrid Larsen, the hospital’s former director of care coordination. “We were hands-off unless there was a problem.”

Rightsizing post-acute care

The Chicago-based hospital (formerly Centegra Health System) wanted a solution to help its case managers improve communication with post-acute providers and steer patients to the best—and most cost-effective—care.

The push to better coordinate care came eight months after the hospital joined Medicare’s Bundled Payment for Care Improvement program. It enrolled 425 high-care patients: those who had congestive heart failure or had a knee or hip replacement.

The hospital partnered with Prepared Health, a HIPAA-compliant cloud and mobile-based care collaboration platform, to link together three former Centegra hospitals with post-acute, home and community-based providers. The connected platform also includes DINA, an AI technology that analyzes patient data and suggests evidence-based interventions to caregivers.

“Now we could foster communication and be proactive with patients before they showed up in the hospital or ER,” Larsen says. “We could intervene much quicker if there was an issue, often preventing second or third hospital visits.”

Reduced readmissions, $1 million net swing

After using the Prepared Health network for 18 months, Larsen says:

  • Readmission rates for chronic heart patients dropped by 12%; readmission rates dropped 29% overall.
  • The length of stay in a skilled nursing facility for knee and hip replacement patients dropped by 4.6 days.
  • The number of knee and hip replacement patients who spent time at an inpatient rehabilitation facility dropped from 5% to zero.
  • The number of knee and hip replacement patients who went to a skilled nursing facility dropped by 25%.
  • Results added up to $700,000 in bundled payment reimbursements, a $1 million net swing from the prior year.

“We saw that when patients are in more communication with all the members of their healthcare team, they’re much more comfortable going to a lower level of care when that’s the best fit,” says Larsen. “We needed to build strong partnerships outside of the hospital so our patients know they are supported and we’re all on the same page.”


Learn more about Prepared Health

See how Northwestern Medicine has leveraged Prepared Health to connect their PAC network, reduce readmissions and make bundles profitable. 




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