MaineHealth uses AI to get the right hospital patients moving early, and home
Maine Medical Center, MaineHealth's 900-bed hospital in Portland, Biddeford and Sanford, has few post-acute rehab beds and limited therapy staff. With Radial Care flagging, on the first day of a hospital stay, the patients most likely to benefit from early mobilization, its care team gets the right patients moving early and home with the right services.
Patients "on the border" flagged on the first day of the stay
About $20,000 saved for each rehab facility stay avoided, and $10,000 for each SNF stay
A post-acute savings opportunity of $2.5 million per year
The challenge: patients who lose strength in the hospital lose their way home
Value-based care is accelerating, and health systems can deliver more care at home than ever: home health, hospice and palliative care at home, hospital at home, remote monitoring and telehealth. For many common conditions, seniors recover as well or better with care at home as in a facility. Facility stays can even do harm, through infections, delirium and blood clots, while mortality is similar and costs are far lower at home.
Getting there starts in the hospital. Patients who get moving early are more likely to go home, and patients who lie in bed lose strength they need to get there.
- Home health agency
- $2,293
- Skilled nursing facility
- $12,163
- Inpatient rehab facility
- $23,170
A common story
An 82-year-old woman was admitted with a mild flare of her heart failure. Her nurses and physical therapists knew that early mobilization would help her keep her strength, but competing priorities got in the way: one nurse was caring for five or more patients, therapists had to put discharge evaluations ahead of mobilization, and sicker patients came first.
She grew steadily weaker, developed pneumonia by day 7, and stayed 10 days instead of the expected 4. She had to be discharged to a skilled nursing facility (SNF).
Could a tool that helps nurses and therapists prioritize the right patients for mobilization, at the right time, have changed her outcome?
Why early mobilization matters
Early mobilization means getting patients moving as soon as it is medically appropriate, typically within 24 to 48 hours of a hospital admission or surgery. In a review of randomized trials covering 2,308 critically ill patients, it raised the rate of discharge home, and in a study of general medicine patients, using a mobility bundle was linked to fewer discharges to rehab facilities.
Better physical health
Better function and recovery, and a lower risk of deconditioning, blood clots and hospital-acquired pneumonia.
Shorter stays, fewer readmissions
Shorter hospital stays and fewer 30-day readmissions.
Better well-being
Better emotional and social well-being for patients in the hospital.
What gets in the way, and what works
Hospital staff want to mobilize patients, but a survey of 568 physical therapists, occupational therapists and nurses at 8 hospitals in 2 states found the same barriers again and again. Training builds confidence, and nurses report less of both than physical therapists. Patients and families can resist mobilization too.
The top barriers
- Not enough time to mobilize every patient
- Not knowing when and how to refer patients to therapy
- Not knowing when it is safe to mobilize a patient
- Low confidence in mobilizing patients
- Too little training in safe mobilization
What successful programs share
- Teamwork across nursing, physical therapy and occupational therapy
- Processes and algorithms that promote early, regular mobility
- Clear roles, including a way for team members to question orders such as bed rest
- Accurate monitoring and documentation
The solution: Radial Care finds the patients "on the border" on day one
The path forward was to identify the patients right for early mobilization in a standard, objective way, and to help the team decide which patients a nurse can mobilize, which need a physical therapy evaluation, and which could benefit from an intensive therapy plan. Radial Care flags those patients on their first day in the hospital and explains why, in plain language the whole team can act on.
Clearly needs a facility
Some patients will need a skilled nursing facility or inpatient rehab whatever happens.
Where Radial Care focuses
On the border
Patients at risk of an unnecessary facility stay. Steering them toward home reduces readmissions, hospital length of stay and the total cost of care.
Clearly going home
Some patients will go home with skilled nursing or physical therapy either way.
What the AI looks at
Radial Care brings together claims, real-time hospital data from Epic, primary care, specialist, emergency, inpatient, post-acute, pharmacy and equipment records, and social risk measures such as the Area Deprivation Index, the Social Vulnerability Index and social needs codes. Representative inputs include:
Clinical
The reason for this hospital stay, recent emergency visits and hospital stays, recent stays in rehab facilities, office visits, and readmissions.
Functional
Medical equipment, age and frailty scores, long hospital stays, musculoskeletal admissions, and signs of declining function.
Social
Housing instability, Medicaid eligibility, living in a nursing home, cognitive impairment, and use of the emergency department in place of primary care.
MaineHealth and Maine Medical Center
MaineHealth is an eight-hospital health system serving Maine and parts of New Hampshire. MaineHealth Maine Medical Center (MMC) has 900 beds across its sites in Portland, Biddeford and Sanford, from community hospital to tertiary referral center, and is the only Level I trauma center in Maine. MMC is part of MaineHealth ACO, which covers 300,000 members.
The challenges
Very few post-acute rehab beds, limited rehab staff for intensive therapy, and many competing priorities in care management.
The priorities
Shorter hospital stays, better patient flow, more mobilization, fewer falls and pressure injuries, fewer readmissions, and fewer avoidable discharges to facilities.
The Enhanced Therapy Pathway
Built during the pandemic, when rehab beds were nearly impossible to find, it gives selected patients enough physical and occupational therapy in the hospital to go home instead of to a rehab facility. Its capacity is limited, so choosing the right patients matters.
In practice: a day-one workflow with the inpatient team
MMC's nursing staff already set mobility goals with therapists for every patient, and mobility is a key measure on several units. Radial Care adds a way to find, early, the patients who need it most.
- 1
Flag
Radial Care flags the patients "on the border" on the first day of the hospital stay.
- 2
Share
The MMC care manager who uses Radial Care shares its insights by secure chat with the inpatient care team: the RN case manager, hospitalist, physical and occupational therapists, and RN director.
- 3
Act
The team puts actionable patients on early mobilization, and considers them for the Enhanced Therapy Pathway.
Two patients, two paths home
Reinforcing a home-first plan
A man in his 90s came to MMC's emergency department from home after an episode of unresponsiveness. On day 1, Radial Care flagged him as "on the border": a potential candidate for a discharge home, whose last stay a year earlier had ended at home with no readmission, and who saw his primary care physician and specialists regularly. The care manager worked with the inpatient team to reinforce a plan for home and encourage early mobilization. He went home with home health on day 4, with no readmission.
Resolving conflicting advice
A 78-year-old man was flagged on day 1 as "on the border", and the therapy evaluations that followed bore that out: physical therapy recommended a SNF, while occupational therapy recommended home care, since the local home health agency could visit as often as daily. The care manager pointed out the conflict to the inpatient team, which planned his discharge and mobilization together. He went home with home health visits and a primary care follow-up within 48 hours, the outcome he and his family preferred.
The opportunity
Post-acute care costs differ widely, and every stay avoided in favor of home care saves the ACO money: about $20,000 for each inpatient rehab facility (IRF) stay and about $10,000 for each SNF stay. Together, that makes a post-acute savings opportunity worth $2.5 million per year.
What MMC learned
- Radial Care's early results are encouraging, both for early mobilization and for showing care teams, patients and families the benefits of going home instead of to a facility.
- Radial Care's recommendations work best when the inpatient team hears them before therapy's first evaluation.
- One staff member must own using it every day: it takes only a few minutes, but it takes consistency.
- Awareness before launch, across care management, nursing, providers and therapy, was key, and the clinical teams received the recommendations well.
What's next
MMC's early results suggest the same approach could serve other priorities: other care transitions, such as to end-of-life care and other home-based care; other settings, such as ambulatory care; specific care pathways, such as social needs; and patients beyond the value-based care population.
As presented at a HIMSS New England webinar, December 10, 2024
Christopher Wellins, MD, Senior Medical Director, Utilization Management, MaineHealth Maine Medical Center, 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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