NOVATO -- Meritage Accountable Care Organization, the ACO established under the Affordable Care Act by Novato-based Meritage Medical Network, is expanding its relationship with Santa Clara-based CareInSync and its mobile-based platform to curb hospital readmission rates into Marin and Sonoma counties.

As part of the expansion, Meritage ACO will promote the use of Carebook, a mobile application developed by CareInSync that helps care teams better follow the status of patients more susceptible to hospital readmission, with additional providers across its service areas, which includes Marin, Sonoma and Napa counties.  

Curbing hospital readmission rates is of particular importance under health care reform, with the Centers for Medicare and Medicaid offering financial incentives for organizations that are successful and penalties for hospitals that don't make significant progress.

 "I think our challenge is that we are responsible for 16,000 Medicare beneficiaries in multiple locations, and in order for us to be efficient, we needed a seamless system and a really efficient way to communicate and connect to hospitals, skilled nursing facilities, hospice, all securely and in real time," said Andrea Kmetz , R.N., director of care management for Meritage ACO. "We will be connected with (patients) via Carebook in real time, rather than once a week in a formal setting, and potentially on a daily basis."

The program, known as the Mobile Care Navigation Network, began with patients treated primarily at Marin General Hospital, led by Marin General Medical Director Susan Cumming.

It will now include some 19,000 Medicare patients in Marin, Sonoma and Napa counties, with two skilled nursing facilities coming on board, 163-bed Novato Healthcare Center and 54-bed San Rafael Healthcare & Wellness, and Hospice by the Bay, which operates throughout the North Bay. Additional talks are underway with major providers in Napa and Sonoma counties, including Sonoma Valley Hospital and St. Joseph Health-owned facilities, according to Ms.  Kmetz.

"We have shown the system to St. Joseph in Napa and Sonoma and they're interested," she said. "Their feedback has been positive." St. Joseph Health operates Petaluma Valley Hospital and owns Santa Rosa Memorial and Queen of the Valley in Napa.

Established just over a year ago as the North Bay's first ACO, the Meritage ACO and its provider partners have seen significant reduction in readmission rates, particularly with elderly, frail patients who often end up back in acute-care hospitals for a number of reasons, oftentimes as simple as misreading or mistaking medications.

Marin General's readmission rate was already at about 11 percent -- well below the national rate of 19 percent, among Medicare beneficiaries -- but with the Mobile Care Navigation Network, the 235-bed level 3 trauma center achieved a 22 percent reduction, to about 2 percent, in 30-day, all-cause readmission rates, along with a half-day reduction in average length of stay. Patient satisfaction has also increased, officials said.

But while stemming readmission rates is laudable and more cost effective, it's not the only motivation.

"I don't think readmission rates are the sole challenge," said Dr. Siva Subramanian, COO and founder of CareInSync. "I think the Marin General readmission rate was quite low. The broader question is health care spending and how to curtail that and doing a better job in ensuring services are delivered, which is the whole point of the shared savings ACO -- that's the primary driver."

CareInSync's system, through a HIPAA-compliant application on mobile devices such as iPhones or Android tablets, enables close monitoring to avoid such situations that could land a patient back in the hospital, thereby improving health outcomes while reducing costs, according to Dr. Subramanian. It's also yet another example a rapidly evolving technological landscape in health care, which should increasingly look toward mobile solutions that can track, measure and report statistical data, he said.

"There's changing dynamics. There's not been so much change in health care in a long time," Dr. Subramanian said. "(Meritage) really liked the fact that we're a mobile, cloud-based IT system. Everything can be pushed to the right provider at the right time.

"What the technology enables is a loose organization with common goals, like accountable care organizations, to collaborate," he added.

Ms. Kmetz, a registered nurse, said Meritage is also in talks with commercial HMOs to extend the program beyond Medicare beneficiaries. The Meritage ACO was designated a "Shared Savings" ACO by the CMS in January 2013.    

“Our goal is to expand this network to a significantly greater extent by having all of our care managers formally adopt Carebook via tablets, with Meritage ACO serving as the hub," she said.