Health06 October, 2017

How MetroHealth stays in touch with patients post-discharge

Hospitals everywhere are trying to figure out how to stay connected with patients after discharge. A successful engagement with patients and families after discharge can lead to faster recovery, higher patient satisfaction scores, lower readmissions, and potentially better reimbursements.

MetroHealth in Cleveland achieved exceptionally strong results after it deployed a new system for care transitions developed by Emmi.

MetroHealth’s specific care transition goals

The hospital wanted to identify which individuals were not transitioning well to daily life and then identify opportunities for process improvement. It also wanted to encourage patients and families to actively participate in their recovery. The solution had to be scalable to avoid resource constraints. And it had to feel personal and build a sense of intimacy with the patient.

“We wanted something that was going to focus on the patient, have some consistency, and also give us back information so we could make change. It had to be a two-way street,” Dr. Laskey noted.

MetroHealth deployed EmmiTransition® interactive series to educate patients on what they need to do to stay healthy at home and gain insight into how they are doing. The series asks patients questions to determine whether they received a discharge plan, scheduled follow-up visits, and filled prescriptions.

By reaching out and connecting with them on key issues that could slow their recovery, hospitals can find out which specific individuals are not understanding their care plan or making good progress, and avoid a costly readmission.

Stellar results on lowering readmissions

By all metrics the project achieved its aims: Medicare readmissions were 44% lower among patients who interacted with the EmmiTransition series. And HCAHPS patient experience top box scores among patients who engaged with the Emmi programs was higher across all categories:

  • Communication with nurses: 16% higher
  • Hospital environment: 18% higher
  • Pain management: 22% higher
  • Communication about medicines: 29% higher
  • Care transition: 28% higher

Implementation is critical

Dr. Laskey brought in stakeholders from across the enterprise to help ensure its smooth rollout. People representing nursing, care management, quality, information systems, patient experience, service lines, and population health were involved from the get-go. This meant that when mid-course adjustments had to be made, the participants and stakeholders already understood the rationale for the project and were invested in its success.

On the patient floors, nurses were trained to explain to patients that they’d be receiving a phone call at home to check on their progress, and that it was important to respond to the calls as they came in with truthful reports.

Surprises in the gaps identified by Emmi interactive calls

When the hospital got back its “red flag” reports on issues surfaced by the Emmi interactive calls, Dr. Laskey says, “We were stunned by how many red flags we identified initially.” The hospital was missing about 64 patients a month who didn’t make a follow-up appointment. “They didn’t have a ride, didn’t know which doctor to go to, or were not scheduled appropriately.”

Another issue that was “really striking for us” was the high number of patients who reported feeling lonely or sad or “losing interest in things” after their hospital stay. Dr. Laskey recruited social workers at the hospital to find them home help or counseling.

She also discovered that patients didn’t understand what a wound should look like as it heals. So she included some Emmi materials at discharge about how wounds should look. “We would never have known there was that need in our population.”

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