Healthcare News & Insights

Partnership lowers readmissions for at-risk patients

More hospitals are taking active roles in improving patients’ treatment across the continuum of care. Because long-term outcomes have become more important in evaluating hospital performance, facilities are partnering with other healthcare entities to help patients stay healthy after they’re discharged. One such initiative has produced positive results for patients with multiple chronic conditions. 

As discussed in an article on the American Medical Association (AMA) websiteThinkstockPhotos-483614997 (1), the University of Tennessee Health Sciences Center partnered with Methodist Le Bonheur Healthcare, a health system consisting of six hospitals and many outpatient clinics, to implement a primary-care-centered model called SafeMed for patients who were at high risk of being readmitted to the hospital.

Besides having a variety of chronic conditions, these patients also had socioeconomic needs that weren’t being met. The SafeMed program aimed to keep them from unnecessary hospital stays.

How it works

As part of the SafeMed program, providers are notified if participating patients have been hospitalized in the past three days. Nurse leaders determine which of these patients might benefit from additional support when they’re discharged from the hospital.

Community health workers visit the selected patients at home shortly after discharge to assess their current health needs. These workers then meet with doctors, pharmacists and nurse leaders and discuss any issues uncovered during the home visits, including problems with care or medication management, so they can be resolved.

The care team continues to meet on a regular basis to evaluate each patient’s recovery and update care plans as necessary.

All patients selected for the SafeMed program are asked to participate for at least three months so researchers can fully evaluate the effectiveness of the strategy.

Along with feedback and support from the care team, patients in the SafeMed program have access to regular peer group support and education sessions designed to make them more engaged in their long-term health. The sessions are led by providers and other health experts. Patients are encouraged to ask providers questions during these sessions, and they can also suggest topics for future discussion.

The collaborative approach has been successful so far. After only six months, hospitalizations went down by 30%. In addition, there were 44% fewer 30-day readmissions, and emergency department visits for patients with multiple chronic conditions decreased by 52%.

4 keys to an effective program

Hospitals can have similar success with their own community health initiatives by working with any affiliated physician practices, or creating partnerships with local primary care providers and clinics.

Per the AMA article, here are four steps the University of Tennessee Health Sciences Center and Methodist Le Bonheur Healthcare used to get started:

  1. Develop a plan. Hospitals should have a plan in place for how they’ll integrate this model of care into their normal operations, including which providers and professionals they’ll work with, and how they’ll present the plan to patients.
  2. Identify patients who may be a good fit. It’s important to know which types of patients your facility will be targeting with this plan. Low-income patients with multiple complex chronic illnesses will likely get the most benefit out of the initiative. Here, electronic health record (EHR) technology will be helpful in filtering out patients based on specific criteria.
  3. Assemble and train your care team. Choose a leader and decide who will be on the care team. Team members should be well versed in your hospital’s workflow, along with disease signs and symptoms, and the necessary treatments and medications. Examples of excellent team members include doctors, nurse leaders, pharmacists, medical assistants, nurses, community health workers and health coaches.
  4. Implement the plan, and review it continuously. Use your hospital’s EHR and other tools to regularly track the progress of participating patients and the effectiveness of your plan. That way, you can make adjustments when necessary, continuing to tailor your strategy to patients’ specific needs and challenges.

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