Enhancing patient recuperation and reducing readmissions
Benedictine Health System (BHS) is a mission-based, nonprofit health system headquartered in Duluth, Minnesota, sponsored by the Benedictine Sisters of St. Scholastica Monastery in Duluth. Through our communities, BHS provides senior care with independent living and complete long-term care services for aging adults, including assisted living, memory care, and rehabilitation. GoMo Health and BHS partnered to create a readmission reduction program for two of the BHS locations.
Improve patient post-discharge recuperation.
Reduce the number of readmissions.
GoMo Health leveraged its proprietary emerging science, BehavioralRx, the science of precision health, to build the program and determine the engagement strategy, approach and content delivered.
The following behavioral and cognitive techniques were applied:
Anchoring Technology / Cognitively connecting the desired action with an existing everyday activity.
Tailoring Technology / Persuasion through customization.
Nurturing Technology / Guided persuasion
Conditioning Technology / Reinforcing target behavior.
Reducing readmissions at Benedictine Health System skilled nursing facilities
GoMo Health implemented a Personal Concierge program for two Benedictine Health System (BHS) locations: Benedictine Health Center at Innsbruck in New Brighton, MN, and The Gardens at St. Gertrude’s in Shakopee, MN.
The program deployed with up to six personalized plans-of-care for 90-days post discharge:
- Chronic Heart Failure (CHF)
- Joint Care
- Sepsis / Wound Care
- General Wellness (Other conditions)
Care Messages™ delivered to patients, family, and caregivers
Patients receive up to 3-5 Care Messages per week via email or text message. Care Messages are designed to help patients manage their condition at home. They offer health-management tips, condition education, general wellness information and escalation paths should their health deteriorate. Messages can also be sent to a caregiver or family members who assist patients with in-home care.
Addressing the challenges of skilled nursing facilities
Skilled nursing facilities often are unaware of a patient’s readmission to the hospital, making communication and support challenging as they are graded and even penalized on patient readmissions within specific timeframes. To track post-discharge health, Personal Concierge surveys patients to see if they’ve had a relapse or returned to the hospital, allowing the facilities to update patient records, while reducing the need for staff to reach back out to patients.
Improving post-discharge follow up productivity
Additionally, 31 days post-discharge, patients receive a text message asking if they have been readmitted to the hospital, and the message is re-sent and/or escalated to a BHS care coordinator as needed to obtain a timely response. This feature allows BHS facilities to optimize both patient tracking and clinical productivity by offloading several routine communications and feedback activities from the clinical team enabling them to spend more time on higher impact tasks with more people.