By Melinda Young
EXECUTIVE SUMMARY
Employees at HonorHealth Network in Phoenix work toward reducing readmissions. This is why the health system created a process improvement program that addresses the challenges of frequent users.
- In 2022, the program reduced readmissions among patients with complex care plans by 51%.
- When patients with complex care plans arrive in the ED, the team opens the record and clicks into the patient’s complex care plan.
- Case managers, ED staff, and others noted they are satisfied with the program.
Reducing readmission rates is an important goal for most health systems. But for one system in Arizona, it is the goal of everyone from the board of directors down to frontline staff.
“Everyone is pretty vested in providing care that reduces the risk of readmissions,” says Pamela Foster, LCSW, MBA, ACM-SW, vice president of care coordination at HonorHealth Network in Phoenix. “About five years ago, we had a network-like summit of key stakeholders across the organization, including hospitalists, case management, and lots of different people vested in readmission reduction across the organization, come together for a day to understand the problem, root causes, and to develop solutions to tackle the root causes of readmission. Several ideas were born, and we created a lot of different processes and standard workflow.”
The idea for improving the way complex care patients were handled was initiated by the hospital’s chief medical officer. The program’s development and outcomes were presented at the American Case Management Association’s conference in April.
The chief result of the project targeting frequent users was a large reduction in readmission rates. “In 2022, we had over 200 patients with these complex care plans in place, and we were able to reduce the readmissions among those patients by 51%,” Foster says. “Many of these patients have complex chronic illnesses where they’re approaching the end stage, and that’s what’s driving them back to the hospital. We may tell the emergency department, ‘This patient has palliative care at home. Let’s contact the palliative care provider.’” This approach ends the cycle of readmissions, and helps patients receive the palliative care they need.
The readmissions process improvement involves a complex care plan initiative. “We look at patients readmitted to any of our sites, and we try to look for opportunities to wrap around that patient and put processes in place to mitigate the possibility of their being readmitted,” Foster explains. “We have a data analyzation tool and can see patients if they’re readmitting, but we can’t see if they’re outside our system.”
They focus on frequent users at every utilization management meeting in the hospital. “Between those meetings, if someone wants to discuss a case, they can pull the team together at any time and talk through these patients to see what they look like,” Foster says. “That’s how we identify them.”
The team talks about the opportunities for preventing readmissions and for handling the complex care plan. The plan is included as a note in the electronic medical record. “We get a lot of input from the team, and physicians will provide input into that plan,” Foster says.
For example, if a patient was readmitted frequently due to abdominal pain, and diagnostic tests have been performed, the hospital would have this information on file and say there was no further need for diagnostics because it could be a pain management issue.
“Here’s the recommended course of action and clinical-directed care,” Foster says. “Then, from a psychosocial standpoint, we may have a palliative care component and put this together.”
When patients with complex care plans visit the ED, the team opens the record and clicks into the patient’s care plan. The emergency physician will receive an alert with a link to the care plan. When the physician opens the link, they will see the patient is a frequent visitor, care that has been administered, and the best recommended course of action, Foster explains.
Case managers and the ED team can access and initiate the plan to prevent the readmission.
“If a patient with a plan like that presents to the ED, a whole bunch of key people get notified, and another system generates an email notification to social workers and the case management director in the hospital,” Foster says. “They are notified to go down to the ED to intervene. We know the patient well, and we can say what we did, what happened, and what needs to happen to stop the admission.”
Depending on the situation and the time of day, the case manager or director will connect with the ED team to make sure they have all the necessary information. Case managers also can help connect hospital providers to the primary care physician and help with medication issues.
“We make sure we have a good plan,” Foster says. “Unless the patient has a new medical problem or an acute exacerbation that has to be addressed at the hospital level, we get those patients [transitioned] out of the ED.”
Transitions home are handled delicately. “We sometimes have different care providers and services come into the patient’s home and increase the care level at home for patients who return home,” Foster notes.
This change to how transitions and readmissions are handled did not require additional case management time and resources. “What we did was build it into the goal for each hospital,” Foster explains. “We have the utilization management committee, where everyone meets, and we have the case management director meet with whoever is pertinent to the case.”
Case management also works with accountable care organization partners to improve the transition process.
The change has been well received, Foster says. “The ED staff really appreciates it, and we’ve received a lot of positive feedback,” she adds. “We’ve worked really hard for these patients, and we’ve put comprehensive discharge plans in place.”
It is satisfying to the team and physicians when they can work together to break the cycle of preventable readmissions. “We don’t have a plethora of beds every day,” Foster says. “We’re running pretty full, and we need inpatient beds for patients who are acutely ill.”
While it takes time to develop the transitional care plans, the case management team is satisfied with their work and the successes. “The case managers do provide input, but the leaders are the ones who are taking their input and putting it all in the chart, so the burden is not on the frontline case managers — but more on the leaders,” Foster says. “Our hospitalists are really engaged in this, too, and they initiate a lot of these. [They also] will reach out and say, ‘We think this patient can benefit from a complex care plan.’”
Once they have improved the process, the team has to keep up with the change and monitor outcomes. “We built it into our visualization tool and can track it that way,” Foster says. “Sharing results of how well it’s working has been a motivating factor.”
Case managers and others like hearing about the program’s success. “The most important thing is it has had such a positive impact on patients and their care,” Foster notes. “It’s never good for patients to keep readmitting to the hospital. For complex patients, this is a great intervention and strategy to provide quality care to them.”
Complex care patients who frequently return to the ED and hospital are among the hardest patients to handle from a case management perspective, so any program that helps is welcome. “This has been an ongoing labor of love, and it’s become one of our most important strategies to reduce readmissions,” Foster says.
Employees at HonorHealth Network in Phoenix work toward reducing readmissions. This is why the health system created a process improvement program that addresses the challenges of frequent users. In 2022, the program reduced readmissions among patients with complex care plans by 51%.
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