Case Study: Trinity Health at Home reduces readmissions with Strategic Healthcare Programs

Decreasing readmissions through hospitalization risk factor data and a robust remote patient monitoring system

Trinity Health at Home (THAH), a national nonprofit home care and hospice organization, faced the significant challenge of reducing high hospitalization and 30-day readmission rates, which were initially at 22.83% and 14.54% respectively. Their goal was to achieve single-digit readmissions and a hospitalization rate below 12% to meet the objectives of value-based care models and improve patient satisfaction. To address this, they partnered with Strategic Healthcare Programs (SHP) to leverage data analytics for identifying patients at high risk of hospitalization.

Strategic Healthcare Programs provided data analytics that enabled THAH to proactively identify high-risk patients from their OASIS data. This allowed THAH to tailor care plans and deploy a robust remote patient monitoring system called Home Care Connect through a 24/7 Virtual Care Center. As a result of this partnership with SHP, THAH successfully reduced its 30-day readmission rate for patients on telehealth to 8.0%, making significant progress toward its ambitious goals.

Trinity Health at Home