A similar effort is in place to identify people with behavioral or mental health issues. "Untreated behavioral health problems significantly affect a patient's ability to stay home," Christopher explained.
The organization also is working with hospital partners on a program called "shave a day," identifying patients who would be better off at home than in the hospital. Thanks to a community-based team, the program has been able to avoid subacute admissions and reduce stays by a day or more for total knee and hip replacements, thanks to a community-based team.
Since visiting nurses cannot be with most patients at all times, the organization is trying some tech-driven consumer engagement strategies. "Telehealth enables patient and family to really seize control of that episode of care," Christopher said.
Nurses and other healthcare professionals are texting with younger patients, such as pregnant women and new mothers, according to Christopher. Texting also has helped boost medication adherence for HIV/AIDS patients.