The accountable care organization reported that, working with one of its health plans, 30-day readmissions for heart failure dropped to 7.55%. The ACO’s pneumonia 30-day readmission rate went down to 9.09%, the COPD rate hit 4.55%, and stroke readmissions dipped to 2.50%.
Triad HealthCare Network (THN), based in Greensboro, N.C., an accountable care organization comprised of a network of six hospitals and 1,200 physicians, achieved these results in part through signing patients up for automated calls from Emmi. The results were reported recently in Healthcare Informatics magazine.
THN also had excellent results using EmmiPrevent® to boost quality scores, leading to higher payments from Medicare.
EmmiTransition® programs use a combination of interactive voice response (IVR) calls and interactive multimedia programs to extend the reach of care teams, gain insight into how patients are progressing on their recovery and to flag potential high-risk responses. Patients receive access to multimedia programs that explain their condition, likely course of recovery and steps they can take to stay healthy at home. Patients also receive regularly scheduled IVR calls over a 30- or 45-day period asking the patient to self-report on a variety of topics depending on their diagnosis – such as their ability to fill prescriptions, how they’re feeling, if they’ve gained weight, or if they are depressed, to name a few. Potentially at-risk answers are flagged and given to the care team in a daily report.
“It’s really an extension of our care management team. When a patient is flagged, the care management team will reach out and call those patients,” says Elissa Langley, Chief Operating Officer for THN. “Some of the things that they commonly find for action is that patients didn’t fill their prescriptions, they didn’t take their medication, they did not weigh themselves for heart failure monitoring, or they are feeling worse, and that would flag one of our care managers to intervene, reach out to the patient and help to knock down those barriers.”
Rates of 60-day readmissions also declined for the health plan. The 60-day readmission rate for pneumonia went down to 4.55% and for heart failure patients, it fell to zero, Langley says.
“This model is pairing the technology, which is helping to scale these calls and ensuring consistency in what information we’re collecting, and then looping our care managers back into play when a patient is activated, or when patients are telling us that they have a need, says Tonda Gosnell, population health project manager for Triad HealthCare Network, an affiliate of Cone Health.
Another of THN’s goals was to improve its patient education outreach. It used Emmi programs to provide medical information, manage patient expectations, and increase patient understanding. “We wanted to have a standardized education platform for our patients. The tool is a library of educational videos that are interactive with the patients, and we really liked that approach,” Langley says.