For its thriving patient-centered care coordination service Care Link, Christiana Care Health System has earned the John M. Eisenberg Patient Safety and Quality Award, the nation’s preeminent recognition for quality and safety in health care.

The award recognizes the best examples of individual, local and national efforts to improve patient safety and health care quality and is jointly presented by the Joint Commission – the nation’s oldest and largest standards-setting and accrediting body in health care – and the National Quality Forum, the nation’s standard setter for health care performance measurement.

Sharon Anderson, RN, BSN, MS, FACHE

“Our success with Care Link stems from a culture at Christiana Care in which the patient and their family is placed at the center of all we do,” said Sharon L. Anderson, RN, BSN, MS, FACHE, chief population health officer, senior vice president of Quality and Patient Safety, and president of Care Link. “The missing link to optimal health is addressing the gaps between sicknesses and health crises. It is ensuring that patients’ social and behavioral health needs — with their great impact on health — are being met, in addition to their medical needs. Care Link’s unprecedented predictive analytics capabilities and innovative work in care coordination improves health care safety, quality, value and access to care for all throughout our state and region.”

Christiana Care received the award for Local Level Innovation in Patient Safety and Quality, which recognizes organizations that have made an extraordinary impact on care at the community level.

Retired teachers Kathryn and John Bailey of Bear say Care Link’s help after Kathy suffered a stroke in January has enabled them to go on enjoying their very active retirement.

Transforming health care

Care Link currently serves nearly 75,000 Medicare beneficiaries and health plan members in the greater Delaware region. Many present with chronic diseases and conditions such as heart disease, stroke and diabetes that are the leading causes of death and disability in the United States, according to the U.S. Centers for Disease Control and Prevention (CDC).

Nearly half of U.S. adults – about 117 million people – have one or more chronic health condition, and account for 86 percent of all health care spending, according to the CDC.

Through Care Link, Christiana Care partners with primary care physicians to transform the way care is delivered throughout the region and accelerates Christiana Care’s journey to achieve better quality and better experience at reduced costs.

Care Link is a robust information technology-enabled network of care coordination support services that builds relationships among providers and patients to optimize outcomes. Unlike traditional care coordination programs, Care Link harnesses a real-time information technology platform that integrates information from regional health information exchanges along with other health information – including admission and emergency department visit information, physician visits, lab results, radiologic reports, pharmaceutical use and claims data.

Care Link is a robust information technology-enabled network of care coordination support services that builds relationships among providers and patients to optimize outcomes. Unlike traditional care coordination programs, Care Link harnesses a real-time information technology platform that integrates information from regional health information exchanges along with other health information – including admission and emergency department visit information, physician visits, lab results, radiologic reports, pharmaceutical use and claims data.

This information is integrated into a care coordination platform that supports Care Link’s interdisciplinary team in providing care coordination services to providers and their patients. It incorporates a prediction analytics engine that uses artificial intelligence and machine learning technology to enable the Care Link team to proactively identify populations most at-risk or in need of attention so issues can be addressed before they escalate.

Delaware’s U.S. Rep. (now Governor) John Carney talks with Care Link Medical Director Tabassum Salam, M.D., and case manager Audra Posey, RN-BC, during a visit to Christiana Care’s Care Link headquarters in 2016.

Making health care more successful for patients and providers

The success of Care Link is borne out by data under the U.S. Center for Medicare and Medicaid Services’ Bundled Payment for Care Improvement program. Since October 2015, more than 8,600 patients in several surgical and medical populations, including total hip or knee replacement surgery and congestive heart failure, have been supported by Care Link.

With the help of Care Link, the number of patients with elective joint replacement who were discharged to their homes with self-care or with home health care increased by 30 percent and the number of patients transferred to skilled nursing facilities after total joint replacement surgery reduced by over 62 percent. For this patient population, there was a 30 percent reduction in readmissions after 90 days.

For patients admitted to the hospital with congestive heart failure, the average length of stay dropped by over 11 percent. The volume of patients being discharged to home with self-care or with home health care rose by nearly 12 percent, with a concurrent reduction in the number of patients transferred to skilled nursing facilities by over 10 percent. The readmission rate to the hospital reduced by almost 14 percent.

To reduce unnecessary hospital utilization and improve quality of care for patients in skilled nursing facilities, Care Link teamed with the staff from local and regional facilities. Strategies included weekly interdisciplinary conference-call patient rounds using a standard template, medication review and reconciliation and social work support. This effort reduced average length of stay by 17 percent, saving an estimated $821,000, and reduced hospital readmission rates by almost 8 percent.

Care Link achieved these remarkable results through technology-enhanced care coordination. A well-connected network of Care Link team members supports patients across the continuum of care from hospital to home. Outpatient outreach starts as soon as patients return home, with a focus on symptom management, follow-up appointments and access to discharge medications, all while supporting primary care and sub-specialty physicians in the care of their patients.

Care Link pharmacist Kelly Ann Steeves, R.Ph, introduces Care Link patient Anthony Tramonte to guest visitor Delaware Gov. Jack Markell in 2016.

Right care, right place, right time

The Care Link team emphasizes educating patients on the appropriate sites at which to access acute care and on minimizing unnecessary use of the emergency department or hospital. The predictive engine identifies patients at highest risk of utilization, allowing the team to customize the intensity of outreach to each patient.

Real-time admission alerts on patients from all emergency departments and hospitals through the regional health information exchanges, along with other health information and claims data, allow the team to interact with hospital clinical and care management teams, helping to avoid unnecessary hospitalizations and ensuring appropriate follow-through on clinical plans.

Created in 2012, Care Link was one of only 107 winners (out of over 3,000 applicants) of a Health Care Innovation Award by the U.S. Center for Medicare and Medicaid Services.

The patient safety awards program, launched in 2002 by National Quality Forum and The Joint Commission, honors John M. Eisenberg, M.D., MBA, former administrator of the U.S. Agency for Healthcare Research and Quality, who was a passionate advocate for patient safety and health care quality.

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