ZynxCarebook Helps Meritage ACO Achieve Successful Reduction of At-Risk Patient Readmissions

LOS ANGELES, March 24, 2015 /PRNewswire/ -- Meritage Accountable Care Organization (ACO) in northern California today announced the results of a two-year care management program designed to help lower preventable hospital readmissions among its highest-risk patients. The Bay Area-wide patient readmission rate dropped to 10.2 percent, placing it considerably below the 17.5 percent national average in 2013 for Medicare patients.

The program combines an internally developed, evidence-based hybrid model of care with a ZynxCarebook™-driven mobile care navigation network that supports secure, patient-centered collaboration among providers in different care settings. The cloud network brings all participants onto a single electronic information-sharing platform, allowing them to collaborate on evidence-based transition plans and follow-up with patients post-discharge.

The program's dramatic readmission process improvement placed Meritage ACO just below the coveted 90th percentile for chronic heart failure, asthma, chronic obstructive pulmonary disease and all-cause 30-day readmission avoidance. For this achievement, Meritage ACO was named a finalist in the prestigious 6th Annual Dorland Health Case in Point Platinum Awards for demonstrating sustained success setting the standard in improving safe, quality continuum of care coordination.

"As an ACO, we have extra incentive to lower readmissions by managing the quality of the care we deliver throughout the entire continuum," said Andrea Kmetz, R.N., director of care management and quality assurance at Meritage ACO.  

"Our providers are spread across 2,600 square miles. The ZynxCarebook platform makes it easy for clinicians and nurse care managers situated at all of our participating facilities to communicate securely about the patients they treat while keeping all care team members informed and updated on new developments. It would be impossible to share such critical clinical information in a timely and efficient manner using traditional phone calls, pages, faxes, or e-mail."  

Meritage ACO is the first healthcare organization in the North Bay Area of California to be designated a Medical Shared Savings ACO by the Centers for Medicare & Medicaid Services (CMS). It encompasses 250 primary care physicians and specialists from its own network and 21,000 beneficiaries across Marin, Sonoma and Napa counties. Other current participants include the 235-bed Marin General Hospital; the 163-bed Novato Health Center and 54-bed San Rafael Healthcare & Wellness Center skilled nursing facilities (SNFs); and Hospice by the Bay, which operates throughout the North Bay region.

In developing the program, Meritage ACO targeted older adults who are at a high risk for readmission as identified through evidence-based tools such as Project RED and Project BOOST^®. Most of these older adults have complex chronic conditions requiring close management, and some have complex psychosocial needs that impact their ability to manage their own healthcare.

Using the evidence-based Coleman Model as the basis of their program, Meritage ACO nurse care managers visit patients at the bedside before discharge to provide care transitions coaching. The care managers explain the process, provide education, answer questions, assess the patient's willingness to engage in their own care needs, and plan for their transition. The next phase of the care management model involves using techniques such as Patient Activation Management Tool and Motivational Interviewing techniques. Lastly, a review of recent care is conducted to eliminate service duplications often occurring between patient care setting transitions.

ZynxCarebook allows organizations to create a HIPAA-compliant mobile care navigation network using iOS and Android-compatible tablets and smartphones. The platform is integral throughout the care transition process, providing checklists to ensure that all proper actions are taken at the right time by the right team member–making it easy to collaborate across a variety of settings.

"Meritage ACO proves that seamless transitional care supported by the use of sophisticated mobile network technology–especially for persons with complex care needs–is essential," said Siva Subramanian, Ph.D., senior vice president of mobile products at Zynx Health. "We are proud of the role ZynxCarebook played in helping Meritage ACO lower its readmissions dramatically while creating a sustainable model of patient-centered, evidence-based care that other organizations can emulate."

A preview of Zynx Health's newest innovations including ZynxCarebook will be showcased at booth #2260 at the Healthcare Information and Management Systems Society (HIMSS) 2015 Conference and Exhibition, April 13-16 in Chicago.

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About Meritage ACO
Meritage Accountable Care Organization (ACO), an outgrowth of the Meritage Medical Network, was the first healthcare organization in the North Bay Area of California to be designated a Medical Shared Savings ACO by the Centers for Medicare and Medicaid Services (CMS). Unlike most organizations of its type, which are hospital-driven or a partnership between a physician group and a hospital, Meritage ACO is physician-owned and physician-governed. It encompasses 250 physicians and 21,000 beneficiaries, and covers a 2,600 square mile service area spanning Marin, Sonoma and Napa counties. The ACO includes hospitals, skilled nursing facilities and hospice providers. To learn more, visit www.meritagemed.com/meritage-accountable-care-organization-aco.

About Zynx Health
Zynx Health, part of the Hearst Health network, is the pioneer and market leader in evidence- and experience-based clinical improvement and mobile care solutions that provide the care guidance to enhance quality, improve care coordination, and decrease variation across an individual's health journey. With Zynx Health, healthcare organizations exceed industry demands for delivering high-quality care at lower costs under value-based reimbursement models. Zynx Health partners with healthcare organizations to continuously and measurably improve care every day, for every patient, every time. To learn more, visit www.zynxhealth.com or call 855.367.ZYNX.

About Hearst Health
Zynx Health is part of the Hearst Health network, which also includes FDB (First Databank), MCG and Homecare Homebase, and Hearst Health International. The mission of the Hearst Health network is to help guide the most important care moments by delivering vital information into the hands of everyone who touches a person's health journey. Each year in the US, care guidance from the Hearst Health network reaches 84 percent of discharged patients, 174 million insured individuals, 35 million home health visits, and 4 billion prescriptions. Extensions of the Hearst Health network include Hearst Health Ventures and the Hearst Health Innovation Lab. www.hearsthealth.com

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