Strive Health, a provider focused on value-based kidney care, has observed that many of its health IT vendors operate within the same value-based care framework, collaborating with accountable care organizations and health systems.

Challenges Faced

Strive Health encountered difficulties in finding a technology vendor that could meet its specific needs, which required the integration of unique use cases into their technology and workflows. This prompted the team to develop their own technology solutions.

They sought a tool capable of:

• Identifying patients suitable for various care pathways
• Utilizing data science and machine learning to align patient care characteristics with Strive’s care model
• Customizing and integrating seamlessly with existing tools used by their care teams, known as Kidney Heroes, which include nurse practitioners, nurses, social workers, care coordinators, and dietitians.

Matthew Temba, Chief Technology Officer at Strive Health, emphasized the importance of ownership in technology development, stating, “We never want our business to innovate faster than our technology, which is why having ownership control is key.”

Proposed Solution

Unlike other vendors that assess a broader population, Strive Health’s technology focuses on identifying high-risk patients within the late-stage chronic kidney disease (CKD) group. Temba explained, “We wanted to develop individualized care plans that address issues early, preventing progression to dialysis or transplant.”

The technology aims to:

• Identify patients who would benefit most from intervention
• Enhance management of these patients’ health, leading to more healthy days at home
• Reduce hospital utilization and generate shared savings through preventative care.

Integration of this technology into existing workflows ensures that care teams are prepared to address the needs of complex patients effectively.

Implementation of CareMultiplier

The solution developed by Strive Health is called CareMultiplier. This technology aggregates and standardizes data from various sources and employs predictive analytics to provide deep insights into kidney patient profiles.

Temba noted, “The model is designed for our internal care teams and our Kidney Heroes, ensuring that all patient-facing staff utilize customized workflows.”

CareMultiplier integrates with systems like Salesforce and AdvancedMD, streamlining documentation and care activities for nurse practitioners.

Results Achieved

In early 2024, Strive Health introduced a new assessment workflow that significantly reduced initial documentation time by nearly 50%, allowing more time for patient interaction.

Key performance indicators (KPIs) tracked include:

• 36% reduction in 30-day hospital readmissions
• 49% decrease in hospitalizations among high-risk patients
• 67% increase in optimal starts for renal replacement therapy.

Temba highlighted the importance of continuous improvement in their risk stratification model, which adapts as new patients are added.

Advice for Other Organizations

Temba advises other healthcare organizations to maintain a long-term vision, despite the challenges of investment and external factors. He emphasizes the need for:

• Building reusable and flexible technology
• Strong relationships between operational and clinical teams to ensure effective feedback loops.

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