Real world data and analytics in home health and hospice with Angela Richards, Director of Health Informatics at Andwell Health Partners (formerly Androscoggin Home Healthcare and Hospice)

In this episode of the Post-Acute POV, our host, VP of Sales for Home and Hospice, Craig Levy, is joined by Angela Richards, Director of Health Informatics at Andwell Health Partners Home Healthcare and Hospice to discuss real world data and analytics and the importance of the patient’s story.

Join Angela and Craig as they cover topics such as using data to develop strategic conversations, what makes a great data partner, remote patient monitoring, and telehealth. This episode provides real world examples of how organizations are using data and analytics to improve workflows and increase efficiencies across post-acute care. Listen to their conversation below.

Topics discussed during today’s episode:

1. [01:06 – 02:07]: Firstly, Angela describes her origin story and how she found her focus on data and analytics at Andwell Health Partners.
2. [02:30 – 05:41]: The pair discuss when data became relevant in post-acute care from a business standpoint.
3. [6:05 – 8:07]: Angela then explains how she uses data to develop strategic conversations around the patient related to better outcomes and how this sets Andwell Health Partners apart.
4. [8:21 – 11:28]: Next, learn what qualities make a great data partner, some of the specific data elements to share with partners, and how to display them.
5. [11:47 – 13:30]: The importance of telehealth and remote patient monitoring.
6. [13:48 – 17:11]: Angela then shares how Andwell Health Partners looks at data differently as a diversified business and which trends are driving different business behaviors.
7. [17:35 – 19:45]: The pair discuss using data and analytics to improve workflow efficiency.
8. [20:02 – 21:14]: Angela offers advice for someone who is not currently using data to improve workflows in post-acute care.
9. [21:40 – 24:06]: Angela and Craig then discuss how clinicians focus on patient engagement and the importance of a patient’s story.
10. [25:23 – 26:02]: Lastly, Angela reveals how she would like the future of data to utilize a centralized format.

Resources

• Find out more about Andwell Health Partners
• Listen to more episodes of the Post-Acute POV

Transcript

Speaker 1

Hi, and welcome to The Post-Acute Point of View, our discussion hub for healthcare technology in the out of hospital space. Here, we talk about the latest news and views on trends and innovation that can impact the way post acute care providers work. And we take a look at how technology can make a difference in today’s changing healthcare landscape in both home-based and facility-based care organizations and the lives of the people they serve. Today, we hear from Craig levy, Vice President of Home and Hospice Sales for MatrixCare and his special guest. Let’s dive in.

Craig Levy

Hi everybody. This is Craig levy. I am the vice president of sales for the home health and hospice division here at the MatrixCare. And I am seven years into MatrixCare and certainly a very exciting time for us and our customers. And very much looking forward to a conversation with Angela Richards, who is the director of health informatics at Andwell Health Partners. And why don’t we start off Angela, tell us a little bit about Andwell Health Partners and your role, and then we’ll jump right into the conversation.

Angela Richards

Thank you, Craig. I’m very excited to be here and working with MatrixCare. I’ve been with the Andwell Health Partners for over 30 years, I’ve had a variety of roles in the organization from boots on the ground doing direct care through project management, as well as being a clinical software support specialist. Andwell Health Partners serve central Maine. We serve over 10 counties. We cover hospice, home care, palliative care, transitional care and telehealth, as well as having a general inpatient unit. Our census runs about 1400 for our home care program. About 300 for our home hospice program. Our inpatient unit, as I said, is 14 beds. Our transitional care program is a program we work with the state of Maine on our Maine care population and has a census of about 600 and we have 450 tele-health monitors, which we use for all of our programs, as well as private remote patient monitoring contracts. I’m really pleased to be working with MatrixCare and what has brought to our agency. We have been with them just under a year and looking forward to many more years ahead.

Craig Levy

Great. That’s appreciate the introduction there. So let’s jump right into the conversation around data. We’ve both been in the business for a while. I like to stop counting because I feel a little aged, but long enough to know that the importance of data has changed. When do you feel like data was relevant in this business from a timeframe standpoint?

Angela Richards

Well, I too have been in the healthcare world back in paper days. We weren’t riding on ponies, but we were out there without much support from [inaudible 00:02:39] in the field. What I have seen is progressive data opportunities that have allowed us to really hone in on patient outcomes and really to focus on improvement initiatives as well as strategic growth. When I started working with Andwell Health Partners, we did convert to electronic health record in 2006. And we also started working some of my vendors such as SHP, which allows us to really look at our home care population and really honing in on our star ratings and honing in on areas that we could focus to do education support with our clinicians, as well as sharing our patients’ outcomes where they need to be to be successful and remain independent in the community.

Angela Richards

We really rely on data as well with our HIE. In Maine, we only have one HIE and we work very closely with them and they help us align very early with notifications of when our patients were being admitted to the ER, or if they were being admitted to the hospital, which allowed us to do quick follow-up on our patients.

Angela Richards

So if they had been in the ER, we were notified that they had been discharged, which would then execute a call so we could get right out there and find out what had happened and what could we do to prevent possibly a future ER visit or possibly another [inaudible 00:03:49] admission.

Craig Levy

Yeah, I think I kind of align with your thoughts to beginning of data was certainly the benchmarking and seeing how maybe you compare to your peers. I remember from a national and state level, that was always important. And then, certainly the evolution of looking at data in all different aspects there. I’ll even go back before that, I saw data as kind of chasing reports and you probably have been seeing that as well, where it used to be where you were trying to chase data, but now it’s easy for data to be pushed to you from a proactive standpoint.

Angela Richards

Exactly. Being able to drill down on reports on a monthly basis or quarterly basis to really focus on areas that you could improve, to also look at readmission rates to really do root cause analysis and then do focal work on populations. As I said, we cover 10 counties. So it’s really important to look at what the population in each county may be dealing with so that you can then give focus support that community in general. We use data also for benchmarking. We work with a vendor [inaudible 00:04:55] who allows us to really hone down our staffing, what our ratio should be, where we are doing nationally, as well as at the state level, in regards to our company.

Angela Richards

And really data drives our strategic movements in regards to growth of our programs, as well as supporting our staff and making sure that we are strategically growing in areas that are being identified as having needs. And it also helps us hone in with our partners. Andwell Health Partners is a nonprofit freestanding home care agency, which is far and few now. So we do not have one large umbrella hospital that oversees us or an ACO entity. So it’s really important that all of our partners know that we are looking at their data, we want to work with them strategically on what their problems are and how we can assess them with their patient care.

Craig Levy

Yeah, that’s a great point. It’s not just about how you use the data, it’s how you use the data outside of your business to communicate with your strategic partners. Can you explain a little bit more about how you’re using that data to develop these strategic conversations around maybe the patients in terms of the outcomes, but also how you’re growing your business with that data as well?

Angela Richards

I think a really good example of that is our palliative care program. I don’t know if I admitted that when I was describing our program setups. Our palliative care program right now runs a census of about 150 and it’s growing by the month. That’s one strategic area that was really brought to focus by data. We had aligned with an ACO in particular, and we’re looking at root cause analysis on readmissions. And it was really apparent people as they’re dealing with chronic disease progress through a normal trajectory and just need that extra support but they aren’t really ready for hospice.

Angela Richards

But yet, they’re getting maybe a little bit ready for some discussions around some advanced care planning or maybe discussions around the symptom management so that they can stay functional out where they are in their homes and communities and still be comfortable and know that they’re in control of their healthcare. That was a really strategic move that was made based on data. And it has really proved to be successful for our organization as well as our partners in our communities. And I think that would be a really good example of how we use that aspect to grow our business.

Craig Levy

Great. And I would imagine that you’re able to use data to really set you and Andwell Health Partners apart from your competition. Can you speak to that in terms of how that helps you really speak to your value when it comes to that partnership?

Angela Richards

Well, I know as we all are aligning with fellow ACOS and partners, which whether it could be a skilled nursing facility or an assisted living facility, really trying to understand what their population health needs and how we can align to support them with their population needs. So really looking at the referral information. I’m looking at what diagnosis is we’re seeing. I’m looking at what supportive services we could provide or assist them with care for their patients, where they are choosing to age in place. I think that’s something that we try to work with our partners on regularly. The ACOs in particular, we are really trying to look into value based purchasing and what the pain points would be around providing them supports to help them improve their outcomes as well as our outcomes.

Craig Levy

Great. And do you see the trends with these type of partners are going to be a little bit more at risk, which is a different kind of, I guess, model, which would drive a different type of data that we’ve seen in the past?

Angela Richards

Yes, definitely. We’re seeing more than at risk or assuming some responsibility for risk, and that is part of a great partnership I believe. And I think by monitoring the data, sharing the data together and then working for outcomes that will improve for them and us is going to be critically important. I think those have grown over the last five years, but I would say over the last year have become more prevalent for risk being associated with our partnership and what we can bring to the table for them. And data will support that and help us with those relationships in the growth.

Craig Levy

So what would be some of the, if we were to get into the weeds, what are some of the specifics, the data elements that you would be sharing with your partners, if you were going to present something to them? How are you getting this data and what would that look like?

Angela Richards

So we’re using a variety of sources for our data, whether it be MatrixCare pulling for referrals by date, by diagnosis, by provider, by region, or whether it’s looking at SHP data for readmissions or predictive analytics towards patients that would be at risk for readmission. As well as looking at Trella data, which is providing us some understanding of referral sources and what their readmission rates are and where we could focus based on readmission rates and what we can do to support them without those populations.

Angela Richards

I think data comes in a variety of different formats and depending on how and what you want to present to your audience is going to be critical. If you’re discussing a contract, you may want to talk about commonality of the patients that you share and where you’re willing to take the risk and where you can bring things to the table to help them with that population that they are caring for that are may be some of them are more challenging patients. I think data is going to drive value-based purchasing and also these risk arrangements and where risk is going to be taken in regards to how they’re going to manage this population that they serve.

Craig Levy

Yeah, that’s great. And I think that really, it’s a very underutilized function of our business, even to the consumer side when you think about they have the patient choice of who they want to choose, if they could use data. The data elements exactly that you’re talking about readmission and other type of ED visits that would drive outcomes, giving them the tools to understand who to choose is also, I think, aligns very strong with their comfort level of choosing a partner or a provider as well.

Angela Richard

I completely agree. We’ve recently also got into a relationship with a vendor called Acclivity that is allowing us to do some predictive analytics on our population that we serve. This will also allow us to align with our referral sources to talk with them about these patients that may benefit from services such as palliative, or supportive services, or maybe even remote patient monitoring as they are working with dealing with the tools that they have stay independent, where they are living. Data is really going to drive not only the capacity of a patient to live alone independently and manage their chronic disease, but also to allow us to look at times where we could provide them with additional resources to perhaps keep them away from being admitted, keeping them comfortable at home and giving them what they need to be able to stay out in the community.

Craig Levy

Well, you mentioned remote patient monitoring, and that’s an interesting part of, I think, a driver to improve the outcomes and efficiencies as well. In particular to that, what is the data that you gained from telehealth to help you better service your patient population?

Angela Richards

Remote patient monitoring has really taken off partially due to the pandemic. But Andwell Health Partners’s been invested in it since 2010, and we really felt it added an extra layer of information as well as maybe a little security for our patients. It also has worked really well with PDGM and visit management and making sure we have the data we need to make sure these patients don’t get readmitted, or at least they feel supported as they’re in their home, improving their health or getting better or staying out of hospital, I guess, would be more of what I would say. So we have a tele-health team that monitors these readings and based on certain parameters, would they engage with a patient either by video or by telephone. And we’re able to then work with our providers out in the field to either coordinate visits, if necessary, talk with their physicians group, if need be.

Angela Richards

And we’ve actually been involved with a home diuretic protocol where we have standing orders that we work with the cardiology centers around patients with CHF, maybe in the third or fourth stage where the patients don’t want to go back to the hospital. They really want to try to do everything they can to manage their CHF at home. I really believe that remote patient monitoring will help drive the way healthcare is delivered. I believe it will also keep our patients out in the communities, being able to monitor their vital signs and being able to interpret these subtle changes that can be addressed without allowing it to exacerbate and result in a hospitalization or maybe an undue mortality that could have been prevented. So I really think remote patient monitoring and all the tools that are going to come out in the next few years are really going to drive some health care initiatives.

Craig Levy

Yeah. It speaks to the two big points here. It’s patient outcomes and the cost of services patients and directly impacting that with the data behind that service is very powerful for sure.

Angela Richards

Exactly.

Craig Levy

So what’s interesting to me is you describe Andwell Health Partners as a business you’re very, very diversified. How would you say being a diversified agency, you look at data differently than say a home health agency that focuses on one business line?

Angela Richards

So I don’t think there’s anything wrong with focusing on one business line. I think Andwell Health Partners has been a very innovative organization, at least my 30 years with them of the 50 years they’ve been in existence. I believe that they see trends and they see the needs in the community and they feel like there are ways that we can address these outside of just standard programs at times. I think the transitional care program that we have is one demonstration of that where the domain is actually invested in a case management model, or it’s not as engaging as home care, but we’re still in contact with our patients. And it’s really driving around social determinants, the coordination of community resources to really help a patient stay independent and home, even if they have a home. At times, part of our responsibility is to try to work with the patient on getting AB at home because you can’t take care of your disease if you can’t even go to bed at night and have a place to lay your head.

Angela Richards

Getting medications is not in the hierarchy of your most immediate needs. So I just really think that it’s really important to remain an agency that is aware of our community and our surroundings and what they need. And like I said, the palliative care program evolved from work out of some ACO contracts that we had, and just really looking at the data and seeing that there was trends on these patients that were getting readmitted like eight times in one quarter. And when you really looked at it, it was nothing that [inaudible 00:15:11] could have been done medically. This person was just deteriorating. The life was being affected dramatically by their chronic disease, which was unfortunately at the end stages and really trying to intervene and having those delicate conversations and really working with the patient on what they want, what they need. And most patients want to be home, and with their families and trying to manage the disease the best that they can.

Craig Levy

Great. Yeah. I think you kind of nailed it with aligning the trends with the data and really trends driving the behavior of your business. And readmissions is probably top of that list. What would be some examples of some other trends that are driving your business behaviors here?

Angela Richards

I think predictive analytics is driving our business and really looking at home care patients in particular and trying to get from SHP as well as Acclivity data. Patients that are trending based on elements that have been collected to show that they could benefit possibly for palliative interventions or discussions. I think that’s going to be something that’s going to be looked at. Another thing that I think that is going to be really important as we progress through these years is, as you’ve heard me mentioned we have a variety of places that we’re gathering data from. And I think having something that can pull all this data together into one source to some degree such as whether it’s a power BI dashboard or something, a one place you can go and look would be an amazing tool. Another thing which we haven’t talked much about that we use data for is really for our clinical managers.

Angela Richards

It’s really important our clinical managers can really look and see what their staff are experiencing, identify areas or trends where we’re having an increased census so we can adjust staffing models, and really looking at the acuity of the patients that we’re serving as well as length of stay and other impacts that would be something that they strategically would want to look at as far as, do we need to do something different? Do we need to now look at the fact that [inaudible 00:17:01] point that we need to add another FTE? So I think there’s external data and there’s internal data, all of which are very important as you’re growing as a home care hospice agency.

Craig Levy

Yeah, that that’s exactly right. Yu can have two different segments of the inside and outside world of data. You mentioned looking at different key elements, like length of stay, or census increases and managing your business. If we focus directly on efficiencies, using data for efficiencies, where would you see the impact using data to improve your workflow?

Angela Richards

So we look at efficiencies in regards to, in home care we look a lot of the PDGM data and we look at [inaudible 00:17:41] and we also monitor the FTEs by site and really try to assure that we have enough staffing models for the patient ratios that we have. And that’s challenge nowadays, nursing shortages and trying to retain great staff is an issue that I think a lot of agencies across the nation are embracing unfortunately. Data is key to that. You know when you hear from your staff, but when you can actually look at the data and really analyze where those areas of your organization that might need a little increased support, increased staffing and working at strategies of where you can actually adjust some of the staffing models based on office and site is a great tool. It has been very helpful for us as an organization, as we plan to market and strategically grow. Should we have capacity and we have infrastructure to make sure we can meet those needs?

Craig Levy

And we talked about taking data and presenting this to the outside world with your partners. What type of data are you bringing together to present to your executive team? I know them very well, but I want to hear your perspective of going to them to show them the business reports in terms of the metrics that are key to them to see success.

Angela Richards

So Andwell Health Partners has monthly ops meetings for each program that we described. And we use the financial information within our MatrixCare platform, as well as we have also used benchmarking vendors to look at our data and present to decide strategic changes. In our home care arena we are looking at our shift data. Of course, for all focusing on outcomes. And then after looking at the outcomes, really trying to strategize, educating and supporting our staff to improve those outcomes with our patients. We also use our remote patient monitoring partner HRS and the tools that they have in regards to reports to provide to providers, showing them the added benefit of tele-health versus non tele-health engaged patients. We use data strategically for all of our operation meetings to really hone in on what our census is, how we’re doing financially, how we’re doing staffing and where we are looking to strategically grow and work with our partners. It’s really key to our infrastructure and our growth here in Andwell Health Partners.

Craig Lev

Great. And what would you say to somebody that is not as savvy as you, Angela, that isn’t really taking advantage of the data that they have potentially in front of them? Any advice that you would give to them being in the role that you’re in playing with Andwell Health Partners?

Angela Richards

But I wouldn’t necessarily say I’m savvy. I believe as a registered nurse, which I am and the 30 years experience that I’ve had and the exposure I’ve had to our partners, that the data is key. It helps have critical conversations, especially with your partners in regards to what needs to occur for them to be supported, to our patients to be supported, for our communities to be supported. And we really just need to focus on, we are a team in essence together, we may not all be connected, but the data around our patients that we all concurrently provide services to is going to in the end ultimately end up being what a patient is able to focus and stay where they want to.

Angela Richards

So it’s like data is what’s driving us to make sure that every patient out there is getting what they need and that we’re doing the best that we can. And I think it’s a great tool. There’s a lot of it. I think over the next 5 to 10 years, I think we’re going to be able to see at [inaudible 00:21:03] and possibly not siloed in a variety of places, that would be the ultimate wishlist for me. But there is data there, it is reliable and it can help you make some very good decisions for your agency.

Craig Levy

Oh, absolutely. And yeah, very well said. You talked about the combination of a clinician and an informatics representation, a representative like yourself. It’s a very good combination to have within a skillset. For sure. Do you find that the clinicians, are they more focused on the patient engagement? Are you able to get them to engage in data as a part of them driving better outcomes?

Angela Richards

Well, it’s going to be challenging. They do have tools at their hand. They have the PDGM tools that will tell them around their visit frequencies. They have the [inaudible 00:21:49] that tells them right when they do their [inaudible 00:21:51] assessment of the needs of the patient. And if they should be considering palliative services for this patient, what kind of risks they’re looking at with their patients. But I think overall, a clinician becomes a clinician because she loves taking care of patients or he loves taking care of patients. And that patient’s story is always going to be important. And I think I want to bring that to this discussion, that data is wonderful and I love data and it’s very interesting and predictive, and you can do a lot of actual things, but never lose the patient’s story because every individual that you engage has a story and it’s the data that helps make that story solid. I just really hold that to my heart. And I think out of anything, I would want that story told here.

Craig Levy

Well, yeah, certainly what a technology partner or vendor wants to do is to never take away the natural relationship that a nurse clinician would have with the patient in the field, but also give them the tools to be successful from a data standpoint, making the right decisions, being prepared to take on a certain type of diagnosis and being ready with the information and data quicker, faster and better. So yeah, I can appreciate the story side that you’re sharing there. One of my final questions for you that we can wrap up with a discussion side here is, with everything that you’re doing today with data, where do you see the future in terms of data and you taking advantage of those elements?

Angela Richards

I think the future of data, it needs to be more centralized into one format, an easy way to be able to look at it as an agency and also understanding that the views of that data need to be altered depending on who the person is that is analyzing the data. So I really believe dashboards are going to be key, whether it be an executive type dashboard, or a clinical manager type dashboard, or even a clinician in the field dashboard. So you know what you need to do for this patient, when you need to do it, or you know exactly where your agency is in regards to referral volume, or perhaps readmission rates or areas of focus. I just think that there are a variety of ways that data can be looked at. There’s a variety of ways that data is presented and you need to know your audience and you need to understand what is the value added for them in order for data to be effective.

Craig Levy

Well, thanks for that insight. I’d say as we wrap up the conversation here, I think we look at data and everybody has a definition, but you’ve really been able to take advantage of growing your business, using it to get patients engaged in their care. Like you said, helping them, that story behind the patient and the clinician is as strong as anything out there, patient outcomes, building better strategic partnerships, which aligns with growing your business and lowering the cost to take care of your patients. You mentioned tele-health, remote patient monitoring.

Craig Levy

All those are key areas of direct impact that you can have with your patients by utilizing the data and then giving you that competitive advantage. I think that with you having the foresight, and the knowledge and the skillset to utilize data and to act on data is a huge, competitive advantage when you think of how you can service your patients. So it’s been very exciting to hear from you directly in terms of the impact that you have in these areas. Is there anything else Angela, that you’d like to share with this audience in regards to your experience with using the data to your advantage?

Angela Richards

The only thing that I could add is, as you’re beginning to renew your contracts with your advantage plans and things like that, data definitely plays a big part going to them with what you have for outcomes in regards to what you can provide and it’s huge. In aligning with your ACO partners or other partners in your community, that data when you come to the table with that data to talk with them about their specific population, it’s huge. It is impactful and it’s actionable. And I believe that that’s going to be the way of the future that you’re going to be seeing that it’s going to be a specific, “What can you do to assist us to improve our patient outcomes? And moreover, what can we do as a team improve overall patient outcome?”

Craig Levy

Very, very good. Thank you so much, Angela, for your time today and thank you for those listening out there. And we appreciate Angela, all your time and your support. And we look forward to the next podcast to better understand the impact of the post-acute market. Thank you.

Angela Richards

Thank you Craig very much.

Speaker 1

the latest episode of the Post-Acute Point of View from MatrixCare. We have a lot of guests and topics coming up that you won’t want to miss. So be sure to subscribe. If you’ve enjoyed today’s podcast, and if you have a topic you’d like us to discuss, leave us a review. To learn more about MatrixCare and our solutions and services, visit matrixcare.com. You can also follow us on LinkedIn, Twitter, and Facebook. Thank you for listening. Be well. And we’ll see you next time.