Problems: Increasing demand for acute care, rising costs. Specialty-oriented, hospital-based approach to acute care delivery. Limited data integration, understanding of acute care utilization at system, population level.
The SHAARPEC approach provided the Region with a holistic, end-to-end understanding of their care delivery. It also helped the management identify potential change initiatives and prioritize between them. The SHAARPEC approach was fundamental in balancing the Region’s healthcare budget. Despite a 4.5% population increase, healthcare costs decreased by 2% while maintaining high care quality.
Problem: A small percentage of the population with complex care needs consumes a disproportionally large share of healthcare resources.
Solution: Implement an integrated care management program based on dedicated nurse care managers.
Using the SHAARPEC approach, the region could identify high-cost patients with several hospital admissions and ED visits per year. They were mostly elderly patients with multi-morbidity and often with mental health burdens. Average annual cost of care consumption for these patients was around 26K EUR/patient, in total around 10% of the total healthcare budget. A dedicated nurse care program for this group of patients enabled them to receive additional care from nurses, at the same time reducing the need for inpatient and emergency care.
Problem: Patients with chronic heart failure (CHF) are re-admitted to the hospital within 30 days of discharge, for potentially avoidable causes, incurring high costs and discomfort for patients
Solution: Mobilize a discharge care planning team to support patients after discharge and reduce the need for low-acuity inpatient re-admissions lasting 3 days or less, further leveraging outpatient care services.
Problem: Many patients with atrial fibrillation are not receiving anticoagulation, leading to preventable strokes.
Solution: Develop a feedback mechanism to providers by linking prescription to EHR data
Nearly 70 strokes, 9% of total acute strokes could potentially have been prevented in the study year. Cost savings through preventing 70 strokes:
Problem: Planning for social care services often takes up to 5 days after patients are discharge ready (DR)
Solution: Implement mobile care teams to support immediate care transitions
Discharge ready days are unnecessary costs for the healthcare system, the patient has no need to be in the hospital. Better care coordination allows the patient to return home earlier.