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 Catholic 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.
The goal of the BHS Personal Concierge program is to improve patient post-discharge recuperation and reduce the number of readmissions.
GoMo Health leveraged its proprietary emerging science, BehavioralRx™, the science of patient engagement, 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 a desired action with an existing everyday activity.
- Tailoring Technology: Persuasion through customization
- Tunneling Technology: Guided persuasion
- Conditioning Technology: Reinforcing target behavior
GoMo Health® implemented a Concierge Care Readmission Reduction pilot 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 is 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)
The patients will receive up to 3-5 care messages per week via email or text message. The GoMo 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.
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, the 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. Additionally, 31 days post discharge, patients receive a text message asking if they have been readmitted to the hospital, and the message is resent 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.