Wilmington, Del.-based Christiana Care Health System received the John M. Eisenberg Patient Safety and Quality Award in April for its Carelink CareNow program. The information technology-enabled network of care coordination support services coordinates care for almost 75,000 Medicare beneficiaries. It is credited with helping the system to achieve a 30 percent reduction in 90-day readmissions.

In February, Carelink CareNow and its medical director, Tabassum Salam, M.D., were recognized by the American Board of Quality Assurance and Utilization Review, which cited the program for its “robust interprofessional care coordination and discharge planning.”

Patty Resnik, vice president of care management at Christiana Care, says the system did have a discharge planning program before it implemented Carelink CareNow, and it included educating patients and families on medications and other issues before handing the patient off to the next provider.

“But that’s where it would end,” Resnik says. Carelink CareNow goes “beyond the traditional discharge model.”

Delaware’s legislature passed its AARP-championed Caregiver Advise, Record and Enable Act last year, but the procedures it mandated were already in place at Christiana Care. “It truly didn’t impact us because we were doing it ahead of that,” Resnik says. “We’re not waiting for regulations to drive what we do.”

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Support services Christiana Care provides include making sure patients can get to their appointments and that their primary care providers know in real time about any health care encounters they may have.

“If any of them have a visit to a hospital or emergency department in the state, we know that they’re there,” says Salam, Christiana Care’s senior physician adviser for population health.

Information technology makes this possible, and the Center for Medicare and Medicaid Innovation provided $10 million in 2012 to build Carelink CareNow’s IT system.

Along with access to the Delaware Health Information Network, Salam says, the system’s other major IT component is an analytics system that scores patients' past medical histories, the number of medications they’re taking and the number of comorbidities.

Every patient receives outreach, she says. The highest-scoring patients receive the highest level of attention, which extends the reach of the system outside the hospital, Salam says, including to the 17 skilled nursing facilities with which Christiana Care works.

The Carelink CareNow team includes physicians, nurses, social workers, respiratory therapists and pharmacists. Salam says the pharmacists play an integral role in reconciling pre- and post-hospitalization medication lists and have been valuable in maintaining patient safety.

No matter how much organizations prepare patients and families at discharge, Salam says, things can unravel once they get home and cope with issues such as behavioral health problems, lack of transportation and “the realization that the family lacks the financial ability to pay for medications or devices.”

Salam recalls one case in which a patient was the guardian of her three grandchildren, and the health system had to arrange for the family’s transportation and signing the children — including one with special-education needs — up for school.

“We realized that had to be in place before we could engage the patient herself,” Salam says. “So we are that glue — that continuity for our patients.” 

Andis Robeznieks is based in Chicago.