Our Inspiration

My 6 person team believes that truly transforming health care requires a big shift where we focus on the at risk population and do everything possible to keep them out of the hospital. Patients, especially elderly ones, who discharge from the hospital have an extremely high risk of readmissions.

At the same time, value based purchasing approaches are totally changing the way hospitals need to think about discharge management. New models like bundled payments and ACOs put the burden and cost on the hospital to ensure a successful recovery and avoid readmission.

What does the Solution Do?

Two things: 1) It helps the hospital find the best post-acute care solution for each patient based on their situation. It takes into account patient acuity, patient choice and cost and strives to find the best solution that will ensure a successful transition. 2) It includes automated follow-up with the patient to make sure that their recovery is on track. We use automated phone calls (or mobile) to check in and make sure that the patient is on a success path (e.g., prescriptions filled, meds understood, have seen or will see primary care) and also checks on the red flags associated with their recovery and other issues in their case mix.

How did we build it?

We use the Microsoft stack (.Net, MVC, C#, SQL Server) plus Twilio for our voice and text communications

One tough Challenge...

One challenge that we face is that there is not yet a reliable source of quality ratings for many types of post-acute care. We solve that by using a combination of what exists (e.g., the Home Health value based purchasing aggregate score that comes from a combination of HHCAHPS surveys, OASIS data and claims) and an ability for the hospital to apply their own ratings and track success objectively.

We're Proud that...

We're especially proud to have developed a highly effective and affordable way to monitor patients after discharge. More importantly, patients like it and they comply.

What We Learned

We're agile in everything we do and this allows us to try things out and shift gears quickly if they're not right or not delighting our customers and their patients.

What's next for Discharge in the Cloud - Triple Aim Tech

We'll be candid... It's not easy to work with hospitals on innovative technology. They're bureaucratic and slow and don't want to pay for anything. Plus, in many cases they've been brainwashed by their EHR vendor (especially if it's Epic) to not work with any other software. So, instead of targeting the hospitals (where we know we can make a huge impact), we've been working with the post-acute care providers (and especially home care).

AthenaHealth is taking a radically different approach by saying 1) we don't need to invent everything ourselves, 2) we'll make it easy to integrate with us, and 3) if there are developers and vendors with great ideas, Athena can partner with them and win together. We like that and see it as a possible path to reach the hospital market (plus we'd love to work with you to enhance chronic care management for primary care and PCMHs).

Why Should You Pick Us?

We understand where healthcare is going We have working high quality software We're in the neighborhood We're truly disrupting post-acute care and chronic care management

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