New Touch Points Keep Patients at Home and Out of the Hospital


Written by Carolyn Erskine

Amedisys is enabling its clinicians to better care for its patients at home and, hopefully, will reduce hospitalizations, thanks to a new high-tech approach. It all starts with an old-fashioned phone call.

A six-month pilot program is underway, deploying predictive algorithms and analytics that integrate directly into Amedisys’ electronic medical record system (EMR). With 43 locations participating across Amedisys’ nationwide network, the program hints at promising future results.

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The key is Medalogix Touch, a product of the only data science company that specializes in predictive modeling and analytics exclusively for home health and hospice providers. The goal is to produce data that delivers insights into patient cases that will remove the need for unplanned and unnecessary hospitalizations and keep patients in the appropriate care setting.

In one case study, the analytical horsepower behind Medalogix Touch lowered overall patient re-hospitalization rates from 20.1 percent to 13.6 percent, dropping risk 6.5 percent.

Here’s how it works.

A call center solution, powered by Medalogix, provides risk stratification and voice technology to place automatic calls. The system uses historical information to predict which patients are at highest risk of readmission. This list informs call center specialists, who reach out to the identified patients to explain the purpose behind the calling program, its initial benefits and to discuss the three questions they will be asked via the automated system:

  1. Are you feeling more tired, weak or anxious than usual?
  2. Are you experiencing new symptoms or health issues?
  3. Do you have any health concerns that you want to discuss with a nurse?

After the initial enrollment call, the caller uses the platform to schedule automatic calls to the patient every day for 14 days, and subsequently three times a week for two weeks, all in the interest of monitoring and managing his or her health status.

Answering “yes” to any of these questions alerts the Amedisys call center that action is required, setting in motion follow-up protocols with the patient’s care center that can ultimately lead to a clinician visit. So far in the pilot program, the average response time between a “yes” response and a call is 26 minutes.

The Medalogix Touch system automatically places all documented patient communication about these phone calls as coordination notes into Homecare Homebase, Amedisys’ EMR, so anyone seeing the patient can view the notes.

Recently, an Amedisys heart failure patient suffering alarming symptoms intended to go to a hospital emergency room. Before the patient got in the car, an automatic call came through to which the patient responded “yes”, which prompted a call from Amedisys. The patient was able to avoid the ER entirely and remain comfortably at home.

“You have to be able to predict on a very regular basis who are your highest risk [patients] and how you are going to alter your care plan so you can stop unnecessary hospitalizations,” said Senior Vice President of Clinical Operations Donna Massie.

Embracing this technology for our patients’ benefit supports one of the company’s main initiatives for 2019: reducing overall acute-care hospitalization (ACH) rates across our national home health network. It also addresses the call from CMS to improve individual patient care, provide better health outcomes for populations and reduce costs.

So far, participating patients report feeling empowered and appreciative. The seemingly simple action of repeated calls and questions provides them with reassurance and encouragement to meet their goals. We’re confident these additional touchpoints will help our patients know we are there to support and care for them and help them stay independent at home.

Stay tuned for official results from this exciting initiative!