Analytics help hospital cut readmissions by 25%

California facility focuses care coordination on highest-risk patients
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El Camino Hospital in California reduced readmissions by 25 percent through the use of predictive analytics and videoconferencing with nursing home staff who care for the most high-risk patients, according to a newly published case study by the College of Healthcare Information Management Executives.

The 443-bed hospital based in Mountain View, Calif., identified 25 characteristics that could help predict whether readmission would be likely and grouped patients by low, medium or high risk. Those factors included the patient's age; where the patient was to be placed after discharge; five diagnoses (congestive heart failure, pneumonia, stroke, sepsis and renal failure); and whether the patient's primary care physician (PCP) was identified in the record.

Based on that information, a banner appeared across the top of the screen on records of high-risk patients to alert everyone involved in their care, allowing them to intervene early and plan accordingly.

What's more, according to the case study, when patients were discharged to nursing homes, weekly telepresense sessions allowed staff to exchange patient information.

"Nurses that are caring for patients who have been transitioned to the nursing home now feel like they are better connected to their patient and also to the prior caregiver," Greg Walton, CIO at El Camino Hospital, said. "They realize that someone is paying attention to the patient's status post discharge, and the communication level is vastly improved."

El Camino began the telepresence program with two long-term care facilities last July, and currently is in the process of adding two more.

Its transition team includes a nurse practitioner, a care coordinator and others as needed; the long-term care facilities pull together nurses, administrators, social workers and others who deal with discharged patients and their families.

"Having these meetings face-to-face really changes the dynamic of the interaction," said Mae Lavente, the nurse practitioner who is the hospital's point of contact for the nursing homes. "It's better than a phone call--it's having a personal interaction. You pick up visual cues from what you see when you talk to them."

The calls require sufficient bandwidth to support telepresence, secure environments to protect patient privacy and user-friendly technology.

With the Centers for Medicare & Medicaid Services levying penalties for higher-than-average readmission rates for heart failure, heart attack, or pneumonia, hospitals--and payers, too--are focused on better ways to identify and better manage high-risk patients. Humana, for instance, recently announced a nine-month telehealth pilot that will provide in-home monitoring to 450 Humana Medicare Advantage members in Ohio with congestive heart failure.

To learn more:
- find the case study (.pdf)

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