SNF Patients Demonstrate Positive Outcomes with Innovative Post-Acute Engagement Strategies

In November 2016, Care Navigation Services (CNS), in collaboration with AT&T Healthcare Solutions, developed and implemented a post-acute patient management pilot program designed specifically to meet the needs of high-risk skilled nursing patients. The results CNS has collected to-date continue to demonstrate very positive outcomes! Patients who completed a 60-day program, which included both remote patient monitoring and CNS’ customized patient-centric coaching techniques, improved their health status over the course of the program. Specifically, the following clinical-quality outcomes have been achieved:  0% readmission rate; 97% pilot program compliance; and 100% pilot program patient satisfaction.

A 78-year-old pilot participant experienced dramatic changes in her health during the 60 days – losing 20 pounds and finally understanding why her limitations on liquids is very important in maintaining long-term positive health status. The average age of patients who completed the pilot is 86, indicating no one is ever too old to be empowered to learn self-health management skills. As one patient stated, “the psychological effect of knowing someone is watching your vital signs and [health survey responses] motivates me to stay on track with my goals.”