Reducing hospital readmissions requires just the right mix of clinical expertise and predictive analytics, according to industry experts. Here are two health systems that are hitting their stride.
1. Atrium Health, formerly Carolinas HealthCare System
James Hunter, MD, chief medical officer at Atrium Health, formerly Carolinas HealthCare System, says the large healthcare system with hospitals, emergency departments, urgent care centers, and medical practices in North Carolina and South Carolina began its journey to reduce readmissions in 2010. At that time, it focused on providing the best care to patients in the acute-care setting.
About three years into that journey, it became clear that focusing solely on the acute-care setting wasn’t enough. That’s why, in 2013, the health system began using predictive analytics to learn the types of supports patients needed outside the hospital or emergency department.
Today, its EHR leverages 42 different variables—which include clinical and socioeconomic information—to determine if a patient falls into one of three categories: low, medium, or high risk of readmission.
Much of this information is captured in patient interviews by case workers. Case workers are able to determine, for example, if patients are able to afford their medications, are experiencing food insecurity, have support from family members at home, and access to transportation for follow-up appointments.
“More and more, these are the things impacting readmissions—it’s not about whether a doctor put a congestive heart failure patient on a statin,” says Hunter.
One program that has grown out of Atrium Health's predictive analytics program is its “Heart Success” program. High-risk patients are seen in a multidisciplinary cardiology transition clinic for 30 days by cardiologists with experience treating patients with congestive heart failure, in addition to nurses, social workers, and pharmacists.
Patients who live within a 45-minute drive to the cardiology transition clinic in Charlotte, NC, receive care in person. Patients further away receive virtual visits facilitated by nurses who come to their homes.
After being seen at the cardiology transition clinic for 30 days, patients are returned to the care of their primary care physicians, who are briefed on their patients’ status through the EHR, says Hunter.
At that point, patients have a lot more knowledge about their disease, the signs and symptoms to look for, and people to call if there’s a problem, he adds.
As a result of this and other programs, Atrium Health has been able to reduce its readmission rate for congestive heart failure patients from 19% to 15%. Hunter notes that this is 10% below the national average of 25%.