Advisory Panel: What Technologies Are You Using to Reduce Hospital Readmissions?

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What technologies are you using to reduce hospital readmissions?

Midas+

We currently have manual analysis and reporting processes in place to look at readmission reduction. However, we are talking with a number of vendors about solutions they offer. These vendors include our HIE, predictive modeling vendors (like Predixion), EHR vendors, and niche software vendors focused on supporting case management / continuum of care.

Unfortunately, this is currently done mainly through brute force, due to the outdated systems we have now. After our big-bang hospital go-live in March of 2014, we will have a very robust platform and tools to accomplish this through our EMRs. We are also collaborating with our state-based HIE to help in this regard.

The task is daunting. We have worked with the hospitalists and our owned practices to identify potential readmissions and aggressively intervene where possible with PCMH staff. No specific technology solutions except analytics/ reports that look for a variety of potential readmits such as late labs that indicate problems and chronic conditions requiring check ins to be sure the patient is compliant. It really is down and dirty outreach. I’d like to hear of a magic technology solution but I have not see one yet.

Our focus has been on leveraging our EMR and patent portal to make discharge instructions as clear and user friendly as possible. The rest of the process is very low-tech: follow-up phone calls to every family.

Other than standard case management tracking and the EHR, not much at the moment.

We have some simple but accurate, home-grown predictive analytics tools that risk stratify patients for readmission, but they are, for the most part, not that helpful in reality. It’s not the predicting that’s the hard part; it’s the intervention. You don’t need a sophisticated predictive analytics algorithm to realize that a post-CABG, 75-year old man with DM, living at home alone, is likely to be readmitted. Many of our patient profiles for high-risk readmission are that obvious, and even more so. The hard part is having the cultural will and clinical processes in place to intervene when we identify a high risk patient. It’s not rocket science. Many readmissions occur because of simple causes at discharge time or at home– surgical site infections, poor adherence to medications after discharge, poor discharge instructions, no discharge medications administered, etc.  In addition to the simple interventions at
discharge, patients come back to the hospital and ER because we offer them no healthcare alternative such as a skilled nursing facility, or family education or other assistance at home.

I believe it is mostly manual process that includes determining root cause of readmission (can’t afford prescription, can’t get to follow-up appointments, etc.) and then attempting to provide solutions at time of discharge.

We are using an electronic version of the LACE score that we developed in-house.

No special technologies… just good old fashioned time and attention. We make sure every patient has a follow-up appointment with their PCP or appropriate specialist. If they don’t have a PCP, we created a clinic specifically to take care of these patients (usually Medicaid or non-insured), and help transition them to an FQHC or similar.

Use of LACE index to identify patients at risk for readmission, alert generated on registration in the ED prior to the triage/clinician encounter, remote patient monitoring/telehealth.

We participate in various collaborations between physicians and hospitals looking at the outcomes of claims billing related to cardiovascular remittance  Technologies employed are interfaces and data analytics solutions such as Hyperion, SSRS, and Cognos.

The readmission programs from various randomized controlled trials. The technology that generally can or should support it comes from analytics platforms found either in the EHRs or possibly the HIE but often times is manual

Technologies is too narrow a question; however, keeping to your question we flag recent discharges at ED and clinic visits in the record so the physician can consider opportunities for intervening other than by admission. Total Care Management a broader, non-technology driven program (early follow-up, calls, home visits, et. al.) focused on congestive heart failure patients–a big cohort of readmissions in our environment.

Timely question. While we need to do what’s right for our patients, we are not ready to cut these out entirely as we need to accept as much business as we can as volume is down across the region. That said, we are evaluating this in the context of analyzing our position on Bundled Payments. Our approach is not all that sophisticated – focus is doing all that we can to identify high risk patients upon admission, using workflow technology to make sure someone will be paying attention, assigning to appropriate care managers and doing what we can to make sure they leave as healthy as possible, re-designing our dc summary output to be as comprehensive as possible and enabling dissemination via our CCD, secure mail, fax, etc – anyway our external providers want it! We are working on strengthening our post acute care relationships and determining how we incorporate our ambulatory care management programs into our pre-dc planning. Connecting the dots sounds so easy but is not pretty….

Good question… we are starting to utilize some ambulatory / outpatient case management strategies that can follow the patient via phone calls for high risk (for readmission) diagnoses. We utilize home health’s involvement whenever possible. In our service area, we have seen the biggest hurdles in avoiding high readmission rates is (a) did the patient get the proper follow-up with a physician and (b) did the patient get (or continue to take) his/her medications. Our patient demographics include highly seasonal farm workers, a high unemployment rate, low / no insurance coverage, and so forth.

Real time alerts when a Medicare patient is admitted to one of our hospitals, triggering rapid intervention by a health coach. Telephone for follow-up calls.  Encouraging patients to enroll in our patient portal to increase engagement.