Oct 1, 2019

Angie Stewart - With more than half of U.S. hospitals facing 30-day readmission penalties in fiscal year 2019, the hospital industry stands to lose an estimated $566 million, Kaiser Health News reported. To prevent future readmissions — and avoid financial losses from Medicare payment reductions — health systems can follow up with patients after discharge, according to David Cerino, CEO of call center services provider Envera Health. "A smooth and effective transition-of-care program is key to keeping these numbers down, whether that be in the emergency department setting or in the inpatient setting," he said. During a Sept. 24 webinar hosted by Becker's Hospital Review and sponsored by Envera Health, leaders from Cincinnati-based Bon Secours Mercy Health discussed how their organization's partnership with Envera Health transformed the patient experience. Mr. Cerino moderated the discussion, which featured the following presenters: Erica Bentley, vice president of clinical services, population health for BSMH Jeff Gill, vice president of virtual health and consumer-centered programs for BSMH Ingrid Kaiser, RN, clinical program director for Envera Health Identifying and addressing outreach challenges Like many health systems, BSMH noticed that some patients were contacted too many times post-discharge — and others weren't contacted enough, Ms. Bentley and Mr. Gill explained. "One of the things we looked to address was duplicative communication with patients [and] how we present a united front as a system," Mr. Gill said. "[We] looked to address the wholeness of patient needs — versus [looking at] one need individually, not making a connection around the patient as a whole and what they need." Simplifying outreach would be key to delivering the seamless, personal care experience that patients expect in today's healthcare environment as their out-of-pocket costs keep climbing. For the clinical operations team in particular, identifying the right level of care for patients was also a high priority. The team didn't have trouble identifying patients who needed lots of help or ones who could safely go home, but determining how to help patients who fell somewhere in between was a bigger challenge, according to Ms. Bentley. "We had great hospital leadership engagement around redesigning care, we did daily interdisciplinary rounds at all of our hospitals, our inpatient case management team is a highly developed team ... and we did have a transition of care program design," she said. "Yet, [we] still [faced] trying to clarify the roles and workflows for the right levels of patients." Redesigning the discharge process To synchronize communications and connect patients with the most appropriate clinical resources, BSMH launched a two-pronged program in its inpatient and emergency settings with Envera's help. The first prong involved postoperatively reaching out to patients via phone. For the ED setting, Envera surveyed patients who had been discharged from 10 facilities within a particular region. Six questions, which related to patients' understanding of discharge instructions, medication compliance, and the scheduling of follow-up appointments, were used to determine a patient's risk of readmission. That information fed into the second prong: planning appropriate interventions. If a patient gave a negative response to certain questions, it was cause for escalation, or taking action to prevent the patient's condition from deteriorating. A similar survey was deployed for the inpatient setting, where medication changes were the most common reason for escalation. BSMH's outreach team responded by providing comprehensive education on medication reconciliation to patients, as well as interventions to overcome financial barriers or access issues. For instance, some patients were given information on where to obtain medications at a lower cost. To avoid back-and-forth communications, Envera and BSMH made sure employees who performed outreach were equipped to facilitate follow-up appointments and connect patients with necessary resources. "Having that person touch base pretty quickly after discharge and remind them of the importance [of a follow-up], or help them facilitate getting a sooner appointment, really helps with decreasing the risk that they're going to be a return patient," Ms. Kaiser said. Results and continuing efforts The interaction with patients enabled BSMH to deliver on its goal of improving care through effective interventions. Of the roughly 340,000 ED patients discharged, 80,664 responded to the question, "Are you feeling better today?" helping care teams develop 57,086 interventional care plans. In addition, patients who interacted with the survey were found to be 13.1 percent less likely to revisit the ED within 30 days. As for the inpatient setting, 41,254 patients discharged from multiple hospitals in two cities were asked, "Are you feeling worse?" About 14,000 responses to this question helped the clinical team develop nearly 6,000 care plans, and the respondents were 17.8 percent less likely to be readmitted. The health system's redesigned discharge process also helped mitigate barriers to care, boost patient satisfaction and loyalty, and increase health literacy among consumers, Ms. Bentley said. But it's clear that Bon Secours Mercy Health isn't stopping there: According to Mr. Gill, the organization plans to use the data gathered and lessons learned to deliver even greater customization, convenience and quality for patients. More articles on patient flow: