CareMax brings more care home and saves over $1.7 million per year
CareMax wanted more of its Medicare ACO members to get the right care at home after a hospital stay, and to reach palliative and hospice care in time. With Radial Care flagging the right patients, and nurse Transition Liaisons acting on it with each hospital's team, facility stays and readmissions fell, hospice referrals doubled, and CareMax saved more than $1.7 million per year.
19% fewer discharges to post-acute facilities, and 25% fewer readmissions
Hospice referrals more than doubled
$1.7 million+ saved per year
The challenge: care follows the path of least resistance
Healthcare providers are overstretched, and after the pandemic they face longer hospital stays, staffing shortages and a growing burden of chronic disease. Too often, care decisions follow the path of least resistance, focused on throughput rather than quality, cost and efficiency. That is especially common when patients leave the hospital: chances to send them home with the right services are missed, and they end up in skilled nursing facilities (SNFs) and inpatient rehab facilities (IRFs), with worse outcomes.
Organizations trying to bring more of the right care home face three headwinds:
- Collaboration between providers and payers is often weak.
- The financial incentives of risk-bearing organizations may not line up with the operational incentives of the organizations that deliver care.
- Few objective tools help care teams send more of the right patients home in real time.
CareMax, a leader in integrated care delivery, saw a chance to improve quality and its performance under value-based contracts by focusing on care transitions.
Two opportunities, one platform
CareMax found two key opportunities: too much facility-based post-acute care, and too little timely palliative and hospice care. For its value-based Medicare populations, it used two modules of Radial Care.
Placement
Finds the hospitalized patients who could safely go home with home-based post-acute care instead of a facility: the patients "on the border".
Hospice
Finds the patients who stand to benefit from a palliative care consult, a goals-of-care conversation, or a timely referral to hospice.
People and process, not just technology
Both modules weigh the whole person: clinical and functional status, the home environment, available family support and social needs. CareMax paired them with real changes in how its teams work.
- 1
Transition Liaisons
Designated CareMax nurse care managers use Radial Care every day. They are skilled at building complex care plans and at reaching agreement across disciplines, from the RN case manager to physical and occupational therapists and social workers.
- 2
Change management
A structured change management process made sure each hospital's discharge planning team understood why each initiative mattered and what part it played.
The results: over $1.7 million saved per year
Together, the two modules saved CareMax more than $1.7 million per year. Placement returned almost $6 for every $1, and Hospice better than $9, both after the share of savings that goes to CMS.
Among 8,936 CareMax Medicare ACO members discharged from CareMax partner hospitals, discharges to post-acute facilities fell 19% below the pre-COVID benchmark with Placement, and 30-day readmissions fell 25%. With Hospice, the rate of referrals to hospice more than doubled.
| Period | Discharged to a post-acute facility | 30-day readmissions |
|---|---|---|
| Pre-COVID benchmark | 18.5% | 10.2% |
| Peak COVID, March to December 2020, with Placement | 10.4% | 11.0% |
| With the COVID vaccine, January 2021 on, with Placement | 15.1% | 7.7% |
Rates are adjusted for case mix.
- Placement
- ~6:1
- Hospice
- 9:1+
Why it worked
- A machine learning system that updates in real time, paired with nurse-driven workflows and strong change management.
- Better alignment of incentives between provider and payer, and a rigorous, evidence-driven approach.
- Every appropriate, timely referral to hospice avoids unnecessary or harmful care: extra hospital stays, nursing home stays and rehabilitation that doesn't help.
What's next
The CareMax approach is a scalable model for other organizations working to improve value-based care, and a template for taking on more value-based care across settings. CareMax has since presented how its nurse-driven workflow cut readmissions and how early mobilization cut facility discharges further.
As presented at the National Primary Care Transformation Summit, December 2023
Bert Moreno, MD, Chief Medical Officer, CareMax, with Anant Vasudevan, MD, MBA, Chief Medical Officer, Radial
Radial technology development was funded in part by the National Science Foundation and the National Institutes of Health.
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