Better Connections for Better Patient Outcomes

Chip Grant, MD

Problem Tech Solves

The U.S. healthcare system wastes billions of dollars on avoidable readmissions. While penalties and incentives have been enacted to improve post-acute outcomes, almost no progress has been made – 83% of hospitals will pay readmission penalties this year. This is because past attempts have focused on hospitals, which have very little control over patients once they enter post-acute environments. In addition, industry-standard, claims-based post-acute quality metrics are 12+ months outdated, self-reported, and do not correlate with outcomes. Watershed helps health systems create high-performing post-acute networks with confidence based on real-time metrics that are proven to correlate with outcomes. Watershed is the first post-acute platform that supports closed loop referrals and fosters continuous improvement for post-acute and social determinants of health (SDOH) providers. Post-acute and SDOH partners are chosen based on transparent, real-time performance metrics that correlate with outcomes. Post-acute and SDOH partners who underperform have a natural incentive to improve in order to earn more referrals. Health systems using Watershed have seen a 50%+ reduction in all-cause Medicare 30-day readmissions, saving millions for the average hospital (and quickly reaching break even) in Year 1 alone. Health systems using Watershed also see a 50% reduction in average time spent per post-acute referral by case managers.

Tech Brief

Unlike service-led solutions available today, Watershed offers an easy-to-implement platform-first approach that enables healthcare providers to build and scale post-acute care management programs using modern software technology. Designed to capture a patient’s clinical and social determinants of health information, Watershed is the foundation for delivering real-time, actionable insights to hospitals and clinical and non-clinical post-acute providers, increasing transparency across a patient’s entire care team. Watershed captures discharge summaries, post-acute care plans, test results, treatment decisions, and patient notes from all members of the patient’s care team. By enabling efficient information exchange and communication between hospitals and post-acute providers and integrating best practices into the post-acute providers’ routine workflow, post-acute organizations can continually improve quality of care, follow best-practice guidelines, and optimize patient outcomes. In addition, Watershed provides data analytics. Pre-built reports and dashboards allow customers to extract insights from their hospitals and post-acute care network. Customers can apply insights towards quality improvement and business goals, and can use Watershed to better understand the variables affecting outcomes and care processes in both their hospital and post-acute care networks. The Watershed platform also includes a referral management tool that facilitates transitions from one healthcare setting to another by using Watershed’s objective, real-time performance measures to connect patients with quality organizations during transitions. Hospital case managers use Watershed to streamline their post-acute referral workflow, but unlike other referral tools that simply make processes more efficient, Watershed’s is the only tool that goes beyond efficiency advantages to improve post-acute outcomes.

Tech Differentiators

Although many post-acute care referral management tools have been implemented in recent years, the lack of improvement in post-acute outcomes shows they aren’t working. Readmission rates haven’t improved over the past decade, and are still costing our health system over $41B/year. Watershed has been compared to, and has replaced, a number of post-acute solutions that may seem similar on the surface, but that are fundamentally different. A Post Acute Referral Tool: All of the first generation referral tools were created and sold with the fax machine as their competition. They make existing processes more efficient, but they have never been shown to improve post-acute outcomes. They do not provide real-time insight into post-acute provider quality or performance. An EHR: Watershed complements EHRs used by both hospitals and post-acute providers by providing additional functionality that they simply don’t have. We seamlessly interface with every major EHR. An ADT Convener/Interoperability Compliance: While they may technically meet the CMS Certificate for Participation for Interoperability rule, they fall short of helping providers actually improve outcomes because they aren’t integrated into a holistic platform that includes the post-acute providers. Social Services / Social Determinants of Health Referral: While they connect to social services, they don’t connect to clinical services. They bring in nonclinical and we applaud that - but Watershed brings both clinical (nursing homes, home health, hospice, etc.) and non-clinical health services (Meals on Wheels, homeless shelters, etc.) into the same network through closed-loop referrals -- in a HIPAA-compliant way.


At Springhill Medical Center in Mobile, Alabama, a Watershed implementation resulted in: > 50% reduction in all-cause Medicare 30-day readmissions > 10% reduction in Length of Stay 50% reduction in average time spent per post-acute referral by case manager Communication response time between providers reduced from days to hours Time to establish home-based face-to-face services following hospital discharge reduced from days to hours Consistent care pathway adherence with complete documentation including social determinants of health and medication reconciliation following hospital discharge > 90% of providers receiving referrals from Springhill participate in collaborative quality assurance when readmissions occur Higher performing and lower cost post-acute network created Testimonial from Springhill CEO Jeff St. Clair: “You can listen all day long about how great Watershed has been for us. Or you can look at our numbers -- each of which represents a life under our care. We cut readmissions in half. And I can assure you that the #1 reason those numbers declined -- and those patients fared better -- is Watershed Health.” Testimonial from Infirmary Health Chief Clinical Integration and Strategy Officer Scott Fenn: “Using Watershed has enabled us to save roughly $5M in our first year alone, and we expect the savings to grow in future years.” Testimonial from Randy Granata, VP Population Health, Ascension Alabama: “It was the timeliness and the accuracy of the Watershed data, and the willingness of our network to share it, that really changed the game.” More information can be found in a recent customer webinar here:

Why Us

Although many post-acute care tools have been implemented in recent years, readmission rates haven’t improved, and are still costing our health system over $41B/year. Watershed is the first solution proven to improve patient outcomes while giving everyone throughout the care continuum the opportunity to improve quality of patient care.

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