Reducing hospital readmissions and unnecessary ED visits

According to the Agency for Healthcare Research and Quality, $4.4 billion in emergency department (ED) visits could have been managed in physician office, clinic, and urgent care center. The American Council on Science and Health notes that hospital readmissions can double the cost of an episode. Unnecessary emergency department (ED) visits and hospital readmissions are two areas where we can easily see the intersection between lower costs, improved outcomes, and higher patient satisfaction.

Since claims data doesn’t always give us the information we need to address unnecessary ED visits or hospital readmissions in a timely manner, AllWays Health Partners uses an external vendor to get real-time clinical data whenever a member visits a network hospital.

Offering education and support
Through our vendor, we receive notifications when a member goes to an ED or is admitted to a hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital, long term acute care facility (LTAC), home health ageReduncy, or hospice care.

Our care management team calls any member who has had an inpatient hospitalization that lasts two or more days, so we can ensure that they have proper care coordination. During the call, we ask questions like:

• Were you given written instructions for treatments, special diets, new medications, etc. at the time of discharge by the hospital staff?
• Do you have any questions or problems carrying out those instructions that one of our nurse care managers or social care managers could help you with?
• Do you understand what to do if your condition worsens?
• Would you like to speak to one of our nurse care managers or pharmacist to ask any questions about your new medication (s) or your medical equipment?
• Are you scheduled to receive any equipment or services at home?
• Did you receive the equipment or did the services start yet?
• Do you have a follow up appointment scheduled?

In addition, our health coaches call patients who have been discharged from the ED with a potentially preventable condition (PPC). The coaches educate our members about outpatient alternative care options such as seeing their primary care physician at their office and telehealth options like Partners on Demand. In addition, the health coaches ask questions to make sure each patient has the information they need to prevent another visit:

• Did you think about calling your PCP’s office to see if they could offer you a same day appointment or information on an urgent care center?
• In your own words can you tell me what brought you to the emergency room?
• Were you provided discharge instructions?
• Do you have any questions/concerns related to your emergency room visit?

We encourage all members who have visited the ED or been hospitalized to follow up with their primary care providers and/or specialists to make sure there are getting the appropriate follow-up care.

Our population health management strategy

Reducing unnecessary ED visits and hospital readmissions is just one part of our Population Health Management Program, which is designed to provide comprehensive, multidisciplinary, and fully integrated programs, services, and resources to support the diverse care needs of our member populations. 

Our population health management strategy is organized into four areas of focus:

Keeping Members Healthy: Wellness promotion programs including health coaching, a 24/7 nurse advice line, and an interactive wellness portal.

Identification and Management of Members with Emerging Risk: Programs that support members with new or existing chronic conditions, who may need support managing their treatment plans and self-management activities.

Coordination of Care for Members with Multiple Chronic Illnesses: Services and programs offered to members with complex medical conditions or challenges requiring more intensive support to prevent more serious complications and disease progression.

Patient Safety and Outcomes Across Settings: Strategies for monitoring patient safety, addressing member’s medication needs and coordinating member transitions across care settings.

Each area of focus has defined targeted populations, measurable goals, and specific programs and services. Although each program offers a unique and distinct value to our membership, our programs are integrated to ensure that the member experience is coordinated. Our population health programs are constantly evolving based on the needs and preferences of our membership.