June 17, 2016
Predictive Modeling News featured our Medalogix Bridge case study with Jordan Health Services. In the same issue they featured Encompass’s success with Medalogix Touch. Find PMN’s coverage of our case study below.
Medalogix Bridge Solution
Increases Patient Hospice Days by 300%
Earlier identification of those likely to die within 90 days allows hospice to attend to patients in need more quickly.
Healthcare technology company Medalogix has released a new case study demonstrating how end-of-life analytics and its workflow solution Bridge can help home care providers increase patient days in hospice. The study, titled “Leveraging Analytics and Workflows to Improve Hospice Care,” details Medalogix’s work with Texas home healthcare company Jordan Health Services, streamlining its home health-to-hospice bridging process and thereby increasing patients’ days in hospice by 300%.
“Studies show that early admission to hospice is a key factor associated with excellent end-of-life care,” comments Dan Hogan, CEO at Medalogix. “Bridge identifies patients who have a high probability of dying within the next 90 days, so providers can have appropriate conversations about the patients’ status and provide options to patients and family with complete information.”
Medalogix’s Bridge technology assessed 100% of Jordan’s patient census every day, a statement says, identifying those at- risk patients and supplying clinicians with a prioritized list of patients for review for clinical eligibility. Additionally, Bridge “conveniently integrated centralized EMR documentation for reference,” the statement adds. “The coupling of data-driven insights and easy access to records substantially decreased the amount of time spent in the clinical review process,” it says, “and allowed providers to attend to patients in need more quickly.”
Prior to using Bridge, Jordan Health Services’ home health-to-hospice solution was manual and time-intensive, the statement also notes. “In September 2014, Jordan implemented Medalogix Bridge technology in three of its 11 branches and saw immediate results,” it says. “By February 2015, Jordan had incorporated the analytics solution across all of its branches.”
Says Justin Miller, Director of Synergy at Jordan Health Services: “With the help of Bridge, we have adopted a synergistic approach to hospice transition — ensuring that the right patients enter hospice at the right time. Not only are our patients able to get better end-of-life care, but we’ve also increased our patient record review efficiency. It’s a win-win for us.” Here are details from the case study:
• Jordan Health Services provides in-home care to patients in Texas, Oklahoma, Louisiana and Texarkana AR, including personal care services, home management, pediatric services, skilled care and hospice. Based in Dallas, it was founded in 1975 by Joe and Jean Jordan in Mount Vernon TX with a mission to “preserve clients’ independence and dignity by providing comprehensive care in the home delivered by professional and compassionate caregivers.” Today, Jordan serves more than 25,000 patients in partnership with Cima Hospice, HealthCare Innovations Private Services and PrimeCare Home Health.
• Jordan was searching for a better way to identify patients who would benefit from hospice care and then facilitate their smooth transition from home health. Jordan found its solution in Medalogix Bridge, a predictive analytics based technology and workflow solution.
• The solution increased total hospice days by 300% and patient record review efficiency by 3 times.
- The topic of quality improvement in the US healthcare system has never been more popular. When you Google the phrase “quality of care,” you’ll find more than 1.8 billion results. The topic is such a point of interest because it’s a challenge. While the US outspends all other industrialized nations on healthcare, quality remains far from elite. In fact, the World Health Organization ranks the US healthcare system 37th in efficiency1,2 .
- Given that health expenses typically increase as people get older, end-of-life care is one area where efficiencies and appropriate care venues can be better examined to provide better care at a lower cost. Research shows that families who believe their loved one was admitted to hospice “too late” are much less satisfied with the overall care experience3. Unfortunately, delayed transference happens more often than not. Even though patients meet the Medicare standards of eligibility for hospice, they are not referred to hospice services until the last few days of their lives.
- For instance:
o 62% of patients are hospitalized in the last month of life4.
o A larger proportion of patients died or were discharged within seven
days of hospice admission in 2014 (35.5%) than 2013 (34.5%)5.
o 25% of Medicare patients die in a hospital instead of their homes6.
- While home health providers are positioned to educate patients about the benefits of hospice, they are faced with the challenge of identifying appropriate patients for the benefit. Additionally, some providers struggle both to establish effective transfer procedures that connect both lines of care and to adopt technologies to underpin the transfer process. When a home health organization misses the opportunity to admit patients to hospice, those patients could experience multiple hospitalizations or lose their choice to live their final days as they wish — decreasing care quality aligned to end-of-life goals.
- A 2016 study published in a special “Death and Dying” issue of the Journal of the American Medical Association shows three things were considered to be associated with “excellent” end-of-life care7:
 Early admission to hospice
 Avoidance of intensive care unit admissions in the month before death  Death that occurred outside the hospital
- As a provider of both home health and hospice services, Jordan is tasked with delivering appropriate care aligned to each patient’s goals. Prior to Medalogix and Jordan’s intentional recharging and realignment of its people, processes, technology and culture, Jordan’s home health-to-hospice bridging process was time-consuming, not easily managed within one technology or platform and without data-based insights.
- The system consisted of:
Identifying patient. A hospice synergy liaison — Jordan’s centrally located team member responsible for identifying and managing all home health patients who could benefit from a hospice conversation — would manually review patient records to gauge appropriateness of hospice care. That required 60 to 90 minutes in review per patient record. The liaison would then add the appropriate patients to a spreadsheet.
Discussing in case conference. After hospice-eligible patients were preliminarily identified, the hospice synergy liaison would present findings to a clinician team through a case conference meeting. Those meetings required opening and closing each identified candidate’s digital health records one by one in no particular order. After the relevant information was presented, relevant nurses would then jointly conclude if formal eligibility should be assessed.
Confirming eligibility for hospice care. Once a patient was identified as a hospice candidate, the hospice synergy liaison would flag the patient on a spreadsheet, complete a clinical evidence form to confirm eligibility and then work with branch liaisons to schedule informational hospice visits with appropriate patients.
Presenting hospice as a possible care path. If the patient chose hospice care, the branch administrator would work to ensure referrals were carried out.
- While the process was advanced in its own right and showed a history of success, growth in home health census revealed the need for a more comprehensive, efficient and scalable solution for identifying and transitioning hospice-appropriate patients. Identifying appropriate patients required a lot of time that could be better spent caring for patients, coordinating communication between the hospice synergy liaison and branches was cumbersome and the process of bridging appropriate patients to hospice was not streamlined or easy to monitor.
- In September 2014, Jordan implemented Medalogix’s end-of-life analytics- based solution, Bridge, in the three. After noticing significant success with the technology, Jordan implemented the technology across all branches. Home health patients who could most benefit from hospice care are
highlighted in a risk ranking according to their relative appropriateness for hospice. From there, Bridge helps organize and operationalize the necessary steps from patient identification to having a conversation with the patient about his or her end-of-life care options.
- Additionally, Jordan refocused some of its people and processes while recharging its culture to achieve patient- focused care. Those changes in people, processes, culture and technology have helped achieve Jordan’s end-of-life quality care initiatives and business goals.
- Medalogix Bridge technology helped specifically through three primary features:
 Data-derived insights. Medalogix’s custom predictive models identify and rank patients who are at risk for death within 90 days. That stratification equips Jordan synergy liaisons with a prioritized patient cohort for clinical review. Additionally, Bridge integrates supporting EMR documentation, which allows a clinician to easily review why a patient is identified as a hospice candidate. Data-derived insights coupled with supporting documentation compresses the identification process from hours to minutes per patient review.
 Customized workflow. Medalogix Bridge’s workflow components enable the synergy liaison to easily coordinate with branch liaisons and administrators to track and monitor patients’ progress toward appropriate end-of-life care conversations and decisions. The workflow steps included in Medalogix Bridge were customized by Jordan to best fit its organization and its processes. Five steps, from “Candidate Identified” to “Patient Transferred to Hospice,” were implemented. Time parameters for each step were created to identify bottlenecks in the process and provide the appropriate support to each team. An “Exception” is triggered for a patient when he or she has remained in a step for longer than specified by the clinical leadership team. Additionally, patient “Monitoring” steps were created to review patients with unique needs.
 Centralized documentation. Within the Medalogix platform, users are able to collaborate regarding the status of the patient in each step without duplicating work — all of the information is integrated from the EMR so there is no redundant data entry. Additionally, instead of relying on their individual methods for identification, participants in Jordan’s case conferences rally around a common platform that now facilitates the home health-to-hospice transfer process. The documentation available in the application also facilitates collaboration with third parties, such as physicians, which streamlines the transfer process
- Jordan realized numerous efficiencies in its hospice bridging process after deploying Medalogix Bridge, including:
“While the process was advanced in its own right and showed a history of success, growth in home health census revealed the need for a more comprehensive, efficient and scalable solution for identifying and transitioning hospice- appropriate patients.”
o Increased review efficiency and accuracy. While it would be impossible for Jordan team members to review 100% of the patient census every day for hospice appropriateness, Medalogix can. Medalogix’s probability- based patient stratification then points Jordan’s synergy liaison directly toward the patients who have the highest probability of passing away in the next 90 days. Because reviewing patients for hospice eligibility requires thoughtful clinical review, that creates efficiency for the Jordan clinicians by prioritizing patients accordingly.
o Increased confidence in appropriate patient venue. In addition to the daily predictive analysis, Medalogix streamlines the review process by consolidating relevant patient information from the EMR to help guide the clinical review process. From there, a Medalogix hospice clinical consultant spends time with Bridge users to educate them about adding comments into the “Qualifying Criteria” area that will support subjective hospice eligibility criteria. Those comments are most helpful when written in a manner that supports Medicare Local Coverage Determination diagnosis. Fine-tuning and documenting the process allows the clinical team to review “Qualifying Criteria” documentation to the patient record within Medalogix, including hospice diagnosis and synopsis of imaging or lab results, in the same manner that a Medicare review would determine appropriateness. That ensures the reviewer can support hospice appropriateness.
o Increased care coordination and accountability. Once hospice appropriateness is preliminarily determined and documented, the Bridge user can create a .pdf in Medalogix and share the relevant information regarding the patient’s eligibility directly with the patient’s physician. That information sharing facilitates objective conversations regarding the patient’s current condition and the appropriate venue of care.
o Increased hospice days. Since Medalogix helps more easily and accurately detect appropriate hospice patients and then streamline and organize paperwork and communication from identification to transference, patients who choose hospice care get to experience their end-of-life care benefit longer. That, of course, allows them more time to make the most out of their final days. After one year of use, Jordan increased total hospice days by nearly 300%.
Predictive Modeling News talked to Hogan about using predictive analytics to move patients more appropriately into hospice.
Predictive Modeling News: Why is it important to get patients into hospice? Are they not getting the right kind of care at home or in the hospital? Are they dying in the hospital or at home? What’s the problem in the current system that Bridge solves?
Dan Hogan: First, our objective is not to get patients into hospice. Our objective is to ensure every patient receives the right care at the right time. The decision to go to hospice is always the choice of patients and their families. It’s of the utmost importance to ensure patients and their families are aware of their hospice benefit at the appropriate time. That’s where Medalogix Bridge comes in. Bridge uses predictive analytics to help us more easily and effectively identify those patients who could benefit from hospice care. That’s just the first step, though. These analytic-based insights are then presented to clinicians, who weigh the insights with their experience, instinct and education, along with the patients’ medical records. From there, if in fact the patient could benefit from hospice care, the conversation is started. If at that point the patient decides he would like hospice care, the care provider, like Jordan, can accommodate that request. Since Jordan used analytics and streamlined internal processes, though, that patient will receive more of the hospice benefit he deserves — that translates into more time at home with his loved ones to better live his final days, and that’s priceless. Interestingly enough, we regularly see that appropriate patients who transition to hospice earlier live longer and their quality of life is substantially better. A recent study published by the Journal of the American Medical Association found that early admission to hospice is associated with “excellent” end-of-life care.
PMN: How did you help Jordan streamline its home health-to-hospice bridging process? What logjams existed, and how did Bridge help dislodge them? Is part of a Bridge installation finding out exactly where things get bogged down in the current system?
DH: We are very lucky to work with a forward-thinking and first-rate care provider like Jordan. Jordan initiated internal goals to ensure the right patients were receiving the right care at the right time by focusing on people, processes, technology and culture. We helped with the technology. Prior to installing Bridge, Jordan’s review process for hospice transition was done manually and without centralized documentation, so it was very time consuming. Hospice synergy liaisons spent countless hours — 60 to 90 minutes per patient — combing through files to identify appropriate patients to add to a spreadsheet for review. The installation of Bridge dislodged logjams by streamlining the process, creating a comprehensive, efficient and scalable solution with data-based insights for identifying and transitioning hospice-appropriate patients. This freed up time that could be better spent caring for patients. By identifying inefficiencies in Jordan’s process, such as the manual review of patient files, we were able to create a customized workflow that best suits its needs, making it easy for synergy liaisons, branch liaisons and administrators to track and monitor their patients on a centralized platform.
PMN: Where did the patients come from who made up the 300% increase in hospice use? Were they in the hospital? At home? What kinds of clues was Jordan overlooking that resulting in three times as many patients using hospice?
DH: The patients came from Jordan’s home health program. The 300% increase in hospice transitions was a direct result of increased efficiency and accuracy. Bridge’s probability-based patient stratification ranks patients in order of their likelihood of benefiting from hospice care. This equips clinicians with a list of the best patients to review first.
PMN: What are the risk factors to identify patients with a high probability of dying? Specific diagnoses? Specific changes in lab results over time?
DH: We consider a number of factors as part of our predictive analytic process. Thus far, we have not found diagnoses to be reliably predictive in any of our models across all of the work that we’ve done. However, we have found that the severity of the condition is a reliable indicator when predicting outcomes.
PMN: Is there a risk factor “tipping point” where providers know that death is inevitable and hospice is the best alternative? Are there patients in a gray area? How do doctors handle those “it could go either way” cases?
DH: Medicare intermediaries provide guidelines to assist in determining if patients are appropriate to elect their hospice benefit from Medicare. Patients are reviewed against these criteria during the admission process, which also requires the physician to certify that the “patient has a life expectancy of six months or less if the terminal illness runs its normal course.” We can all benefit from a conversation regarding our end-of-life wishes and choices; however, the actual certification of a hospice patient falls to the clinicians and physicians.
PMN: What kind of patient census does Jordan manage? How big does a home health agency need to be for Bridge to be worth the investment?
DH: Today, Jordan serves more 25,000 patients; it’s using Medalogix Bridge to manage roughly 2,500 patients on the skilled home health census. Medalogix clients vary greatly in size. We have clients that have close to 500 patients on their census, as well as clients that have more than 70,000.
PMN: So, Bridge provides both a list of patient names and details from their medical records on why they’re on the list? Does human intervention ever override the Bridge results? Even though Mrs. Jones is on the list, and her charts back it up, the doctor decides she’s not a good candidate for hospice? Does that ever happen? If so, what kind of factors would a doctor weigh in making that call?
DH: Bridge is designed to work in conjunction with clinicians’ instincts, education and experience — because even though analytics can do a lot, our algorithms may not know that Mrs. Jones is awaiting the birth of her great-grandson. That’s a big deal.
A clinician may know this, though, and would be in a position to say, “You know what? Although the data is suggesting that Mrs. Jones may benefit from hospice care, I don’t believe the conversation is appropriate yet.” Our predictive analytics technology is not designed to make the decision about hospice appropriateness. Instead, our predictive analytics technology is designed to make sure the clinical review and conversations about hospice appropriateness are happening at the right time for each individual patient.
PMN: What did Jordan’s home-care-to-hospice solution look like before? What does “manual and time-intensive” mean? Was Jordan’s system typical of home health agencies that haven’t switched to a Bridge solution?
DH: By “manual and time-intensive,” we mean that Jordan’s previous system was not sufficiently automated, requiring those giving care to spend extra time identifying appropriate patients for hospice — time that could be better spent caring for patients.
“After the first limited installation of Bridge in three of Jordan’s 11 branches in September 2014, the number of hospice days began to climb immediately, reaching a 63% increase by January 2015. After the full implementation began in February 2015, the number of total hospice days increased steadily, reaching 300% in just over one year of using Bridge.”
PMN: What kind of results did Jordan see in the first limited installation? Was it close to a 300% jump?
DH: After the first limited installation of Bridge in three of Jordan’s 11 branches in September 2014, the number of hospice days began to climb immediately, reaching a 63% increase by January 2015. After the full implementation began in February 2015, the number of total hospice days increased steadily, reaching 300% in just over one year of using Bridge.
Medalogix is Nashville-based. Founded in 2012 by Hogan, a former home health agency owner, it has been recognized by Harvard University, the Healthcare Information & Management Systems Society and Fierce Healthcare IT as “an innovative solution that’s improving America’s healthcare system.” Medalogix offers three solutions: Touch, which automates a home health clinical team’s touchpoints, Bridge, which helps identify and inform patients who would benefit from hospice care, and Nurture, which identifies patients who might need further home care in the future.
- “Measuring Overall Health System Performance for 191 Countries.” Ajay Tandon, Christopher JL Murray, Jeremy A Lauer, David B Evans. GPE Discussion Paper Series: No. 30 EIP/GPE/EQC. World Health Organization.
- OECD Health Data 2011; WHO Global Health Expenditure Database.
- Teno JM, Shu JE, Casrett D, Spence C, Rhodes R, Connor S. Timing of Referral to Hospice and Quality Care. J of Pain and Symptom
Management. 2007; 34: 120-125.
- The Dartmouth Atlas, 2013.
- National Hospice and Palliative Care Organization (NHPCO) Facts and Figures 2015.
- Goodmen D, Morden N, Chiang-Hua C, Fisher E, Wennberg J. Trends in Cancer Care Near the End of Life. Dartmouth Atlas Project. 2013.
- Bauchner H, Fontanarosa P. JAMA Death, Dying and End of Life. 2016.
Originally published in Predictive Modeling News.