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Chasing the Triple Aim: Care at Hand’s Digital Model


Care at Hand’s new information-sharing platform can be used on any device.

The right information in the right hands at the right time really can enable smarter healthcare at a lower cost. Case in point: Lawrence, Massachusetts-based Elder Services of Merrimack Valley’s successful health coach program, enabled by Care at Hand’s tablet-based application.

By partnering struggling home-care patients with health coaches, Elder Services of Merrimack Valley avoids costly readmissions. These coaches develop follow-up plans to manage patients’ medications, schedule doctors visits, and alert those doctors to red flags that could point to a worsening patient condition. They also create a personal health record to facilitate communication and continuity of care. Since July 2013, these health coaches have used tablet-based point-of-care surveys to make this happen.

These surveys, powered by Care at Hand, are in common, non-clinical language. They adapt to an individual patient’s particular health conditions. Health coaches provide responses to the survey questions via Care at Hand’s tablet-based application, and any red flags raised by responses to the survey questions will trigger e-mail and text alerts to a care manager with more clinical training.

This is valuable because, once the care manager is informed, they can move to a more hands-on care model with the patient and determine necessary interventions – with the goal of avoiding hospital readmissions. This system works, too. Elder Services of Merrimack Valley has achieved a 39.6% reduction in readmissions and a net savings of $370,721, according to a study conducted by mHIMSS, a mobile initiative of HIMSS.

Care at Hand is the major player here, serving community-based organizations like Elder Services of Merrimack Valley, as well as many other organizations that are untouched by EHRs, according to Andrey Ostrovsky, MD, the software company’s CEO and co-founder. “Historically, these are organizations that previously weren’t using software that contributes to outcomes,” he says.

Today, Care at Hand clients use this application to get data from hospital EHRs, effectively tying together the acute-care setting and home/community settings, two parts of the healthcare system that hadn’t been tied together before, according to Care at Hand.

“We’re still in the nascent stages of what that means in terms of achieving the Triple Aim,” says Ostrovsky, referring to a framework developed by the Institute for Healthcare Improvement for optimizing health system performance.

“We’ve got interoperability standards and, separately, we’ve got quality standards,” says Ostrovsky. “What needs to happen is a marriage between interoperability standards of technology and quality measure standards of interoperability.”

That day is coming, according to Ostrovsky, and he and his colleagues are working toward that goal right now. “The real Holy Grail will be when we don’t have quality measures that are mostly about what the hospital’s quality of care looks like, but what the whole spectrum of quality of care looks like, including what happens out in the community.”

Aine Cryts

Aine Cryts

    Aine (“ONya”) Cryts is an on-staff contributing writer for MedTech Boston. She's a political scientist by education, a writer and marketer by trade. She has written for various healthcare technology publications and also served as marketing director at several healthcare software companies in the Boston area. Cryts is an avid volunteer, pet lover and long-distance runner. Story ideas are always welcome.

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