Recent statistics show that more than 20% of healthcare costs due to emergency department use, hospitalizations, and readmissions can be attributed to just 1% of patients.
PROBLEM
In 2017, the University of Virginia Health’s 30-day readmission rate for patients with complex and costly medical conditions was as high as 17% to 18% per year. This places the health system in the 50th percentile of similar academic medical centers nationally and near the bottom of academic medical centers in the state.
This is problematic for two reasons. From a serious business perspective, the counter penalty cuts back on revenue. Second, from an operational perspective, re-admitted patients can redirect beds and resources that can be used to care for patients with more intensive healthcare needs.
“In addition, industry research and our own experience suggest that up to 20 percent of rehospitalizations can be prevented,” said Teresa Radford, RN, clinical program coordinator at UVA Health. . “We believe UVA Health has an opportunity to improve the quality of care we provide as well as health outcomes and reimbursement by enhancing care for ‘super users’ – typically those patients with complex health and social needs.”
PROPOSE
UVA Health convened a multidisciplinary team to explore best practices for improving health and well-being for people with complex health and social needs.
Often, these patients are dealing with a variety of conditions, from a physical to behavioral health diagnosis. They also face social determinants of health such as unstable housing or homelessness, food insecurity and lack of transportation.
“Our team believes that personalized care plans, or ICPs, have strong potential for improvement,” said Dr. Amber Inofuentes, medical director of the Medicine HOME program at UVA Health. health of ‘super users’ of care while reducing readmission rates. “They can also help alleviate the strain on health system resources that occurs when patients don’t receive the right interventions at the right time.
She continued: “The ICP was developed by a team of nurses, social workers, pharmacists, clinical care coordinators and physicians involved in the care of each patient. “They provide clinicians with a summary of the social and medical histories of enrolled patients and review previous usage patterns to better understand the challenges they face. .”
From there, ICP provides care teams with insight into how to best manage patient care and the types of interventions and resources that can help support better outcomes, she added. . Because care plans are integrated into the EHR, it supports consistent care and communication across care facilities, including in the emergency department.
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MEET CHALLENGES ONLY
The UVA Health HOME Medicine program launched in 2017 with a cohort of 10 adult patients with sickle cell disease. At the time, these patients accounted for 7% of total 30-day readmissions for general health services at UVA Health and nearly $1 million in annual costs.
“A multidisciplinary team of doctors, nurses and mental health professionals created an ICP for each individual,” explains Radford. “Our patient enrollment criteria included at least one chronic illness or behavioral condition that contributed to frequent hospital visits and multiple use of hospital services.
“We define ‘super use’ as four returns in the last 30 days in the last 12 months,” she continued. “The results were impressive: the 30-day readmission rate for 10 sickle cell patients was reduced by more than 65% and the number of days in hospital was reduced by 40%.”
The pilot program was so successful that UVA Health extended the program in 2018 to patients with other complex medical conditions including diabetes, substance use disorders, end-stage renal disease, and kidney disease. many other diseases.
“The challenge, however, is that many patients with these diseases face important social challenges such as unstable living conditions, food insecurity and lack of transportation,” explains Inofuentes. “They are also often the most frequent users of ED — often in multiple locations across the state.
“To help ensure consistent high-quality treatment no matter where they seek care, we needed a way to expand individual patient access to ICPs to ED providers outside of UVA Health ,” she continued. “We started a partnership with CommonWealth’s Emergency Department Care Coordination (EDCC) program using technology provided by PointClickCare to notify our Medicine HOME Program care coordination team of any when a registered patient seeks care at any ED in Virginia.”
PointClickCare’s technology integrates with UVA Health’s EHR and leverages ADT feeds and an extensive care collaboration network to push notifications to point-of-care clinicians.
“For example, when a Medicine HOME patient arrives at the ED, real-time alerts built into the network will notify the case manager at the start of the visit,” Inofuentes notes. “The care coordination team can then provide the physician with the patient’s ICP to ensure optimal care and treatment.
She continues: “We are always trying to break down barriers to care and care silos – especially when it comes to treating our most vulnerable patients. “Our work with PointClickCare and EDCC supports a well-coordinated and informed approach to improving care and reducing costs for patients with complex diseases.”
For example, in a recent case, the UVA Health team received a warning that a Medicine HOME patient diagnosed with end-stage renal disease and experiencing homelessness had visited the emergency department of a health care system. other health systems.
“We were able to contact that ED to inform them of this patient’s housing condition and request a transfer to a skilled nursing facility,” Inofuentes said. “We can also direct them to the patient’s individualized care plan, leading to better outcomes for the patient.”
RESULT
The impact of the Medicine HOME Program on the care of patients with medical and behavioral health challenges is undeniable, Radford reports.
“A 12-month pre-analysis of 37 patients enrolled in the program showed that overall, inpatient and/or follow-up hospitalizations were reduced by 30%; re-admissions were reduced by 46% and total cost of care reduced by 20%,” she said.
She continued: “In addition to reducing hospital usage, the Medicine HOME program has focused on improving the quality of care for complex patients rather than reducing the amount of care. “For each of our complex disease subtypes – diabetes, substance use disorders and sickle cell disease – we have developed quality metrics so we can focus our efforts on its programmatic drive for patient-centered outcomes.”
For the diabetes cohort, data analysis showed a significant reduction in adverse events including episodes of diabetic ketoacidosis and hospitalizations requiring intensive care units and a greater reduction in adverse events. severe hypoglycemia.
“Our program also intentionally seeks to reduce the ‘contrary to medical advice’ (AMA) discharge rate, a low-value approach with proven harms in vulnerable populations. hurt like we are,” Radford explained. “A recent analysis of all enrollees showed a statistically significant decrease in the number of AMA discharges among enrolled patients who had one or more AMA discharges prior to enrollment – an odds ratio deviation 0.28.”
TIPS FOR OTHER PEOPLE
Inofuentes advises: “Try to implement a person-centred model of care and break down institutional, inter-institutional and interdisciplinary barriers and barriers to care. “Emphasis should be placed on seeing the patient anywhere in the continuum of care – e.g. emergency room, tertiary acute care, ambulance, community, and/or home environment.
She continues: “A concise, comprehensive ICP, carefully crafted by the individual patient’s healthcare team, is essential to the success of any complex care program described. adapted from the UVA Medicine HOME Program”. “Also, there’s an old saying: ‘You can’t measure what you can’t track’.”
She said: “Clearly defining distinct patient groups, identifying your most important metrics and tracking specific, patient-centered outcomes is critical to evaluating effectiveness.” of a program.
“Ultimately, we recommend linking your datasets to capture program outcomes and effectiveness,” she says. “It’s also important to allow sufficient time to assess the effectiveness of your program. Patients with complex care with high levels of utilization often have multiple social determinants of health that are not can be resolved satisfactorily within weeks or even months The program’s impact should be assessed over the years.
“Ultimately, no matter how good your ICP may be, its usefulness is only as good as its accessibility to your patient’s health care team – including those outside the care system. take care of your own health,” she added. “Leveraging software-based solutions, such as an ADT-based care collaboration network integrated with an EHR, can help ensure the right care professionals are contacted whenever a patient finds seek care outside of your health system.”
Doing so, she says, will facilitate a highly integrated approach to care delivery that improves health and helps ensure the right patient gets the right care at the right time.
