Healthcare Headlines Blog

Improve Patient Outcomes through Post-Discharge Virtual Care

By Sean R. Muldoon, MD, MPH, FCCP, Chief Medical Officer, Kindred Hospitals

New approaches to care management are required as our nation faces a wave of aging Americans with new and increasing healthcare needs. Adding headwinds to this scenario are the anticipated physician shortage and a continued push toward value-based care.

In this whitepaper, learn the benefits of virtual care and the strategies providers should be considering now to take advantage of the growing technology.

The Need for Virtual Care

The demographic numbers are quite striking:

  • By 2030, there will be more than 80 million Americans 65 or older – up from 56 million today.
  • Not only is a larger aging population anticipated – they are also expected to be sicker, with more than 66 percent of Medicare beneficiaries having two or more serious and costly chronic conditions.
  • A recent report by the nonpartisan Congressional Budget Office (CBO) stated that “while the sheer number of older adults is rising, so too is the cost of their healthcare as individuals are more frequently living with multiple chronic and complex medical conditions.”

This comes at the same time our nation is looking at an impending physician shortage. According to the Association of American Medical Colleges, the US is projected to have a shortfall of up to 121,300 physicians by 2030. Additionally, when the need for geriatric care is rapidly growing, data from the National Resident Matching Program shows that only 35 of the 139 geriatric fellowship programs were filled in 2018.  

This “perfect storm” of the growing number of older patients needing care solutions with fewer specialized physicians to meet their needs, also comes when the Medicare program and other payers are increasingly demanding value-based care.

In order to drive value and a positive patient experience with fewer resources, providers are increasingly turning to a new solution – virtual care. Earlier in the year, Modern Healthcare predicted that a significant growth in virtual care was a top trend for 2019. Virtual care programs will become increasingly important, particularly for chronic care management.

Infographic: Population Increase in 65 or Older: 2019-56 million in 2030-80 million. Projected Physician Shortfall: Shortfall of up to 121,300 physicians by 2030.

What Is Virtual Care?  

“Virtual care is a broad term that encompasses all the ways healthcare providers interact with their patients without seeing them in person. In addition to treating patients using telemedicine, doctors will use live video, audio and instant messaging to communicate with their patients in a variety of ways. This may include checking in with patients after an in-person visit, monitoring their vitals after surgery, or responding to patient questions.  

“Simply put, the term virtual care is a way of talking about all the ways patients and doctors can use digital tools to communicate in real-time, regardless of whether the doctor is using this technology to treat a patient. While telemedicine refers to long-distance patient care, virtual care is a much broader term that refers to a variety of digital healthcare services."

Encouraging Virtual Care

Over the past several years, the Centers for Medicare and Medicaid Services (CMS) has recognized the value of telemedicine and virtual care. For several years, including in the 2019 payment rule, the agency has added HPT and HCPCS physician codes for Medicare to encourage adoption of activities including virtual check-ins, remote evaluation and interprofessional internet consultation. It is anticipated that Medicare and other payers will continue to incentivize adoption of virtual care.

Physicians agree that virtual care programs will become invaluable to patient care. Deloitte’s 2018 Survey of US Physicians found the top benefits were reported by participating doctors as being:

  • Improved access to care
  • Improved patient satisfaction
  • Staying connected with patients and caregivers

Challenges to Adoption

Despite predictions for major growth in virtual care and telemedicine, there are still significant barriers to adoption. According to Deloitte’s 2018 Survey of US Physicians, only 14% of physicians have video visit capability and only 18% of the rest plan to add the ability in the next one to two years.

Physicians cited the top challenges to telemedicine and virtual care as lack of reimbursement, complex licensing requirements and the high cost of technologies – not to mention the security measures needed to protect patient privacy.

One way providers can bridge these obstacles is to partner with post-acute providers or other entities who already offer virtual care solutions, thereby gaining access to existing resources and infrastructure.

Case Study: Kindred Hospital’s Successful AfterCare Program

At Kindred, we saw an opportunity to enhance the patient experience as well as offer continued clinical support to our patients to prevent a decline in their health status – especially those who were transitioning directly home. Recognizing this need, and the role of virtual care, we developed an ongoing care management and patient engagement service called AfterCare, a program that is offered by and facilitated through our Kindred Contact Center.

As part of this virtual care solution, the AfterCare program features Registered Nurses telephonically reaching out to patients, on a scheduled timeline, in order to identify and manage clinical gaps and medication regimens to prevent patient decline or hospitalizations.  

Our patients receive calls at 24-48 hours, one week, two weeks and 30 days post-discharge to assess their progress and identify any post-discharge needs. We break down these identified needs into four groups:

  • DME: Did they receive it and do they understand it?
  • Medications: Were they able to get their prescription medications filled? Do they understand them? Do they have enough ‘critical’ meds to last them to their scheduled PCP follow-up appointment?
  • PCP Appointment: Is it scheduled in an appropriate time frame?
  • Post-Discharge Services: Have they been initiated and is the patient/caregiver satisfied?

In addition to the telephone support, before discharging, our Case Managers are proactively identifying and addressing patient needs. Post-discharge, should an identified need arise through a follow-up call, we will initiate the intervention process.

The first year of this pilot program proved incredibly successful for Kindred Hospitals and our patients.1 For patients within the AfterCare program, from July 2016 through May 2017, the program produced many benefits such as:

  • A decrease in the rehospitalization rate, from 7% to 2%*1
  • The percentage of patients discharging with an identified need decreased from 21% to 6%

Results in 2018 were even more impressive for Kindred patients in the AfterCare program:

  • The rehospitalization rate within the first 30 days declined to 0.6%*
  • The percentage of patients with an ongoing satisfaction concern was also less than one percent

This program is offered to all Kindred Hospital patients as they transition home, and the success can be tapped into and shared by all of our referral partners.

To learn more about how Kindred can help your patients through virtual care solutions, please Contact Us.

Infographic: Our patients receive calls at 24-48 hours, one week, two weeks and 30 days post-discharge to assess their progress and identified any post discharge needs.


*Patient Reported Data


By Sean R. Muldoon, MD, MPH, FCCP, Chief Medical Officer, Kindred Hospitals