Marquis Cuts Readmission Rate By 60% with Patient-Tracking Software Pilot

In less than six months, a skilled nursing provider in the Pacific Northwest cut hospital readmissions by 60%, and its director of data analytics credits a novel pilot partnership with a growing software provider.

Starting in May, the Milwaukie, Ore.-based Marquis Companies rolled out Collective Medical software at three facilities in Oregon; at the time, the buildings had a combined average readmission rate as high at 19% in certain months. Once training was complete in June, that number had fallen to 15.9%, and as of the end of October, the trio reported an average readmission rate of 6.3%, for an overall drop of more than 60%.

The collaboration helped Marquis — which also owns the consulting and therapy firm Consonus — solve what director of data analytics Anthony Laflen described as the “fundamental flaw” inherent in most electronic health record (EHR) systems.


“Nursing providers, when they look at data, can only see what happens in their four walls,” Laflen said.

But the program from the Draper, Utah-based Collective Medical Technologies expands an individual SNF’s data window to include multiple area hospitals. Should a former Marquis resident seek treatment at one of these acute care facilities, the SNF provider receives an instant notification, and its medical staff can work with the hospital to determine if the patient could be better treated back at the Marquis facility — thus avoiding a costly rehospitalization.

“You don’t need to readmit them,” Laflen said.  “Send them to us.”


Readmissions have leapt to the forefront of many skilled nursing providers’ concerns in recent years, as new payment models place a significant premium on keeping former residents out of the hospital and in their homes. In addition to pressures from Medicare Advantage plans and accountable care organizations (ACOs), operators face an automatic 2% cut in their Medicare fee-for-service rates if they fail to meet certain readmission improvement benchmarks under the recently introduced Value-Based Purchasing (VPB) model.

Providers can earn that cut back if they lower their readmission rates, but the first set of program data from the Centers for Medicare & Medicaid Services (CMS) implied that’s easier said than done: Nearly three-quarters of the 15,000 providers in the country will receive some kind of cut under VBP, with only about 27% capturing the bonuses that CMS provides to the operators with the best readmission progress.

But that readmission window consists of the 30 days after a patient is discharged from a skilled nursing facility, meaning the operator doesn’t necessarily have direct control over the type of care that he or she receives in the home setting. Plus, if a resident attempts to receive care at a hospital, the SNF may never find out about the visit — and the patient may be discharged from the hospital to another skilled nursing facility entirely, further confusing the overall care process.

“That back-and-forth — those repetitive visits — is something that is normally buried in the data,” Laflen said.

Aggressive expansion into post-acute

Collective Medical isn’t the only company that offers software designed to follow patients across the entire continuum — PatientPing, a Boston-based platform, operates similarly — and demand for these services is likely to grow as the pressures on SNFs mount.

For its part, Collective Medical only branched into the post-acute space about a year ago, according to chief medical officer Benjamin Zaniello. The software provider had largely focused on hospitals and accountable care organizations, but soon realized the value that it could provide to those clients by embedding its software in the skilled nursing world; just like SNFs, acute-care providers have a vested interest in knowing the fates of their patients once they leave the hospital setting.

To that end, Collective Medical currently offers its services to SNFs at no cost, a strategy that Zaniello calls the “sponsorship model.” Under current Medicare payment systems, Zaniello said, hospitals and ACOs derive a disproportionate amount of value from tracking software compared to their post-acute partners downstream — and as a result, the company has no current plans to charge SNFs.

“We took a fair amount of a gamble deciding to invest in post-acute, and using the sponsorship model, and I think we are now seeing the benefit of having done so,” he said. “We’re the largest national care collaboration network, and we believe that as we bring on each node, they will strengthen the rest of the network.”

Marquis is just one of multiple skilled nursing providers that Collective Medical has folded into its network over the last year, with a particular focus on easy integration with an operator’s existing systems. The firm has partnered with post-acute EHR giant PointClickCare to fold its alerts into users’ existing setups, with additional similar collaborations currently in the works, and Zaniello noted that the software can also provide less tech-savvy operators with fax and e-mail alerts about its patients.

“In a geography, as we work with the hospitals, hospital associations, health plans, ACOs, they will tell us: ‘What are the critical post-acute clinic networks that support care collaboration?’ And we’ll make it available to them,” he said.

Written by Alex Spanko

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