Collaboration Designed to Improve Care Transitions, Reduce Readmission in Rural Areas
Frontier Medicine Better Health Partnership (FMBHP) and Vree Health – a wholly owned subsidiary of Merck Sharp & Dohme Corp. focused on technology-enabled services designed to improve the reach, cost-efficiency and effectiveness of healthcare – has announced a collaboration designed to improve care transitions and reduce hospital readmission rates for patients in rural areas. Over the coming months, FMBHP and Vree Health will develop new, improved processes for transitioning patients from hospital to home within at least 10 Montana communities that will be pilots to inform later programs.
“While transitional care is a challenge throughout the health system nationwide, rural communities like these in Montana have unique needs,” said Denyse Traeder, director of FMBHP. “We are excited to partner with the experts at Vree Health to develop new approaches to improve the transition from hospital to home in these areas.”
The FMBHP project, funded through a $10.5 million Center for Medicare & Medicaid Innovation Grant, plans to implement TransitionAdvantage™, Vree Health’s post-discharge service, within the FMBHP-served community in an effort to improve post-hospital patient care and hospital efficiency in rural Montana. The TransitionAdvantage service is designed to help patients who were hospitalized for heart attacks, heart failure or pneumonia to adhere to their hospital’s recommended post-discharge care plans, and to help hospitals and other healthcare providers identify potential health issues in these patients before those issues become urgent and potentially costly.
“Rural patients discharged from tertiary care centers often head back home, hundreds of miles away from the hospital,” said Kyle Dolbow, president of Vree Health. “TransitionAdvantage is designed to help improve patient handoff, post-discharge follow-up and medication management. Our high-touch service model helps patients improve their follow-up care and assists hospitals with reducing unnecessary readmissions. This can help with both care and costs in communities like those served by FMBHP.”
The TransitionAdvantage technology platform integrates with a hospital’s Electronic Medical Records system to provide data accessibility and connectivity to the entire care team, including hospital staff, primary care physicians, patients and family caregivers. Vree Health’s Transition Liaisons, serving as daily health coaches, are assigned to each patient before he or she leaves the hospital to conduct daily phone calls, log key parameters and transfer health issues to the respective healthcare provider. These Transition Liaisons, combined with 24/7 access to a nurse hotline and scalable, digital tools, offer hospitals a cost-effective way to utilize their resources and improve patient care.
FMBHP members and Vree Health will begin identifying implementation strategies immediately. By the third year of the project, FMBHP anticipates that a total of 48 critical access hospitals and rural health centers will be included in the network and eligible for TransitionAdvantage. These centers serve 100,000 beneficiaries of Medicare, Medicaid and the Children’s Health Insurance Program. The goal is to standardize improvement efforts and operational processes based upon best practices, resulting in better healthcare outcomes and efficiencies.