Beeline Reader
In 2015, Ashley Barrow, Founder and CEO of RE-Assist, took on the responsibility of helping her family member, age 33 at the time, navigate end-stage renal disease which led to a hospitalization. The hospital discharge was imminent, but her sister could not retain discharge information and Barrow, as power of attorney, was not educated or aware of the rehab levels of care. “We only had the options presented to us for her recovery through a paper choice list directory. It was merely explained as physical rehabilitation for the next step to recovery.” Soon after her sister was admitted to a Long Term Acute Care Hospital. Although Barrow had years of experience in institution to community care management, she felt helpless in the situation and learned quickly that this process is unique and complicated depending on the condition of a patient and recommended therapeutic intensity levels. “Still today in 2022, I am finding there is no clear process on rehabilitation levels of care relating to therapeutic intensity, interoperability, and potential outcomes for planned recovery of function as patients transition through care,” says Barrow.
“Transfer of care is essentially the clinical hand-off between levels of care. Say for example, if someone goes from being in the hospital to home healthcare, or a hospital to a skilled nursing facility,” explains Barrow. She adds, “We specialize in skilled transfer of care. This typically happens when someone has a decrease in function or lack of support and can not care for themself. They may need to be connected to other people, services, or goods to help them.“
The transfer of care process doesn’t stay confined to just a physician and patient; interactions happen between case managers, therapists, vendors, insurance companies, and even family members.
Just as Barrow was an advocate for her sister in her time of need, she aspires to help other people navigate care transitions, which is why she developed RE-Assist. RE-Assist is a digital health platform that has the potential to replace the traditional paper choice list directory that patients choose from to determine their next level of care. The platform allows case managers to streamline the process of finding appropriate care options for patients. RE-Assist can inform case managers on bed availability, insurances accepted, skilled services available, and more. Through automation, RE-Assist will save case workers hours of time manually hunting for the right services through established peer relationships, service provider education, past experiences and online resources.
At the end of 2021, the health care and social assistance industry was among the top three sectors of work experiencing resignations. “Industry knowledge is leaving when case managers are going to other careers. This is impacting organizations and families,” says Barrow.
Health networks may benefit from RE-Assist to mitigate case manager/care coordinator stress, burnout, and retention issues.
A customer discovery interview held by Barrow revealed that 80% of hospital-admitted patients are assigned to case management, making it even more evident how utilized their services are.
Barrow has found that many case managers and care coordinators can spend hours searching for transfer of care options for their patients. Oftentimes, there is not a match due to insurance prerequisites, bed availability, or some other factor. When case managers do find a fit, they are eager to share those options with patients and their families but it’s only a partial list of services. “At times, the first few facilities who say yes to accepting a patient are what patients are being offered because case managers get so many uncertain leads. We want patients to have more firm options and hear yes more frequently,” says Barrow.
Discrepancies in transfer of care can correlate to hospital readmissions, which may even lead to fines and penalties under the Hospital Readmissions Reduction Program (HRRP), among other costs.
In 2011, there were approximately 3.3 million adult 30-day hospital readmissions in the United States, which amounted to $41.3 billion in associated hospital costs. In 2018, readmissions increased to 3.8 million 30-day all-cause adult hospital readmissions. And of late, this figure may be impacted due to Covid-19.
Barrow is seeking to pilot RE-Assist. She shares, “We’re looking for a hospital with an innovation arm and that will let us do Lean innovation – and let us implement the RE-Assist framework and platform to make sure our user interface is intuitive and proves the concept. We believe RE-Assist will increase utilization between providers, decrease length of stay in hospitals, increase patient satisfaction, and expedite referrals while also reducing the manual care coordination hours spent during discharge planning.”
RE-Assist is a 2022 Care Economy Solver team. If you or your organization are seeking to support health innovations like RE-Assist, learn how to get involved here.
