TriHealth, a not-for-profit health system in Ohio, confronted a widespread challenge in modern healthcare: ensuring effective care coordination after patients are discharged from hospitals. With 140 care sites and a network that includes over 200 skilled nursing facilities (SNFs), TriHealth recognised that traditional communication methods were no longer sufficient. Patients discharged into post-acute care (PAC) settings often became difficult to track, creating significant risks for readmission and delayed recovery. In response, TriHealth implemented a digital solution to enhance collaboration between hospitals and post-acute care providers. The results were substantial: the system improved patient outcomes, streamlined clinical processes and reduced annual healthcare costs by millions of dollars.
Overcoming Legacy Communication Barriers
Despite the growing adoption of electronic health records, TriHealth faced serious limitations in post-discharge care coordination. Once patients left the hospital for an SNF or similar PAC facility, clinical teams lost real-time visibility into their status and progress. Updates were typically obtained through faxes and phone calls—manual methods that were slow, inconsistent and administratively burdensome. This lack of timely information made it difficult for care managers to detect early signs of complications or to intervene before a hospital readmission became necessary. As a result, TriHealth’s readmission rate from SNFs reached 25%, while the average length of stay in these facilities rose to 25 days.
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This model was untenable, especially for an accountable care organisation (ACO) participating in value-based care programmes. Without a reliable way to monitor patients after discharge, TriHealth’s ability to meet quality metrics and control costs was severely compromised. Leaders within the ACO set an ambitious goal: reduce the SNF readmission rate to 20% and bring the average length of stay down to the same number of days. Initially, this target seemed unrealistic given the manual nature of existing processes. However, it was clear that a fundamental change in information sharing and care coordination was necessary.
Implementing Real-Time, Predictive Coordination
TriHealth responded by implementing a post-acute care collaboration system designed to eliminate manual data collection and provide actionable, real-time clinical insights. The new platform was integrated with the system’s electronic health record and deployed across 45 facilities. Its primary objective was to replace outdated processes, such as checking fax machines and making numerous phone calls, with a digital interface that would support efficient, accurate and timely communication between hospitals and PAC providers.
The system provided daily visibility into admissions, discharges, therapy documentation and clinical progress at each facility. It offered care managers a complete view of patients’ health trajectories, enabling more informed decision-making and prioritisation. In addition to streamlining data flow, the platform included a predictive component that assessed each patient’s risk of hospital readmission. This algorithm identified rising risk levels and highlighted potential contributing factors, allowing care managers to focus their attention on the highest-risk individuals.
With this enhanced insight, care managers could spend less time navigating administrative systems and more time collaborating with SNF clinicians on proactive care plans. The ability to triage effectively based on up-to-date clinical data marked a substantial improvement in TriHealth’s approach to post-acute care.
Quantifiable Impact on Care and Cost
The results of this transformation were both measurable and far-reaching. TriHealth successfully reduced its readmission rate from 25% to 18%—a 28% improvement. The average length of stay in SNFs fell by the same percentage, from 25 to 18 days. These improvements not only enhanced patient outcomes but also aligned with the system’s value-based care objectives. Based on internal analysis and comparisons with accountable care benchmarks, TriHealth estimates it will save at least €7.44 million ($8 million) annually as a direct result of these improvements.
The benefits extended beyond financial outcomes. The working experience of care managers significantly improved as they were relieved from many of the time-consuming tasks associated with manual data entry and information gathering. With more time to focus on clinical responsibilities, care managers could practise at the top of their licences, offering more targeted, timely interventions for patients at risk. Families also benefited from the increased transparency and communication, especially when evaluating and selecting SNFs—an area where awareness and guidance are often lacking.
TriHealth’s success in modernising its post-acute care coordination demonstrates how targeted digital transformation can deliver major improvements in both patient outcomes and system sustainability. By replacing fragmented, manual processes with an integrated, predictive platform, TriHealth not only reduced hospital readmissions and shortened SNF stays but also achieved substantial financial savings. The system enabled care managers to operate more efficiently and focus on what matters most—delivering timely, effective care to patients at risk. For other health systems navigating the shift to value-based care, TriHealth offers a compelling example of how technology, when implemented with clear goals and clinical alignment, can redefine the post-acute care experience.
Source: Healthcare IT News
Image Credit: iStock
