The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: reducing readmissions (page 1 of 2)

Managing High-Needs Patients can Help Improve Outcomes at Michigan Hospitals

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Only about 5% of patients are considered high-need, yet these patients constitute nearly 50% of total healthcare costs. High-need patients typically have more complex diagnoses and significant barriers to accessing healthcare that impacts the self-management of their condition(s) outside of the hospital. In a recent, pre-publication report, Effective Care for High-Need Patients, the National Academy of Medicine (NAM) outlines various characteristics of high-need patients, patient taxonomy models, along with care models. This report is a compilation of feedback from relevant workshops, presentations, discussions, and literature and stresses the importance of identifying and managing care delivery to high-need patient populations.

High-Need Patients Characteristics

To better create targeted initiatives in a hospital setting for high-need patients, there needs to be better identification of characteristics using data. Although there is not one, specific definition of “high-need patients”; functional limitations, complexity of care/disease, and health care costs are all characteristics that can be used to identify and analyze these patient populations. These characteristics not only impact the care that is delivered within the clinical setting, but also the ability for that patient to self-manage their health outside of the hospital.

High-Need Patient Taxonomies

NAM reviewed two patient taxonomy models in use by the Harvard T.H. Chan School of Public Health and The Commonwealth Fund to better segment patients for improved identification of high-need populations. Using a taxonomy model can guide health systems to more suitable integration of behavioral, social, and functional characteristics in the patient care plan outside of the clinical setting. What is unique about the taxonomy developed by NAM is that it builds upon clinical and medical characteristics to identify behavioral health and social factors that affect care delivery decisions. More detail about this starter taxonomy and a conceptual model can be found here.

Successful Care Models for High-Need Patients

This NAM report also uncovered common characteristics among care models that are successful in managing high-need patient populations. The report mentions that successful care models typically expand upon domains related to health and well-being, care utilization, and costs. Furthermore, these care models include details on dimensions related to service setting focus, care attributes, delivery features, and organizational culture. By targeting a specific high-need patient population (ex: age group), health systems are better able to create care models and initiatives geared towards improved, more integrated care delivery. The report also outlines an analytic framework that helped NAM identify successful care models for high-need patients.

The MVC Coordinating Center can help member hospitals identify domains and care utilization of high-need patients.  If you are interested in identifying these populations within your hospital, please reach out to Deby (debevans@med.umich.edu) or Abeer (abeery@med.umich.edu).

Interested in learning more about optimizing care delivery for high-need patient populations? More information and a copy of Effective Care for High-Need Patients can be found below:

https://nam.edu/effective-care-for-high-need-patients/

https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf

Reducing Readmissions through Quality Discharge Planning

Deby Evans

Deby Evans is the Site Engagement Manager for the MVC Coordinating Center.

According to various literature, the quality of discharge planning can affect the likelihood of readmission. As hospitals search for ways to reduce their readmission rates one of the components to review might be the quality of discharge planning. A recently published study found that not only did higher quality discharge planning result in reduced readmission rates, but it also helped hospital retention rates for those patients that did need readmission. Retention of patients is important not only to maintain continuity of care but also for financial reasons. To read more on the study click here: http://journals.sagepub.com/doi/pdf/10.1177/1077558716647652

So what does quality discharge planning entail? Another recent study showed that quality discharge planning not only effectively informs patients about their discharge plan, but includes ways in which patients will carry out the plan and have the ability and willingness to execute it. In order for patients to become more actively involved in their discharge plans, hospitals should work in conjunction with their outpatient clinics and utilize many of the available community resources they may have. To read more on this study click here: http://qualitysafety.bmj.com/content/26/1/7.full

Two facilities that have incorporated liaising with outside agencies for quality discharge planning and to ultimately reduce readmissions are: The University of Virginia Health System and Christian Hospital in St Louis.

The University of Virginia (UVA) Health System has developed their Hospital to Home program to focus on the two-week time period after discharge. On the morning of discharge, the members of the entire patient care team meet with the patient thus incorporating all aspects of the patient’s care in to the discharge plan. To also help reduce confusion over the discharge plan, UVA Health System provides the patient with an easily understood discharge summary; one that contains no uncertainty or dubious information. This discharge summary is reviewed not only with the patient but with a family member as well. For heart failure patients, a one-hour long appointment at an in-hospital clinic is scheduled between four and seven days after discharge. During this appointment, a nurse practitioner reviews medication and diet. For more on UVA click here: http://www.hhnmag.com/articles/8327-case-study-post-discharge-planning-cuts-readmissions-at-uva

On another note, Christian Hospital in St Louis worked with 911 dispatchers and paramedics to reduce the utilization of their emergency department through the Community Health Access Program (CHAP). To help provide patients with the appropriate support they need, Christian Hospital set up access centers with coordinators who develop relationships with patients and are able to help procure resources. The development of CHAP has helped reduce overcrowding in the emergency department, reduce utilization of ambulances and paramedics and improve the quality of life for many in the community. For more on the CHAP program click here: https://www.christianhospital.org/Community/CHAP

Interested in learning more about Hospital to Home programs? Click here: https://cvquality.acc.org/initiatives/hospital-to-home

 

 

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