Featured Practice: Southaven Internal Medicine – Reducing Hospitalizations for Diabetic Patients

Reducing unplanned hospital readmissions is a goal all our MidSouth PTN practices strive toward, and this week, we are proud to share the tremendous work that Southaven Internal Medicine has done to reduce hospitalizations for diabetic patients. Through new collaborations with hospitals in their medical neighborhood, implementing new patient follow up procedures, and enhanced patient engagement, SIM has reduced hospitalizations from 7% to as low as 1%.  

Southaven Internal Medicine, located in Southaven, Mississippi, provides high quality primary care that is sensible, cost-effective and personal. Providers prioritize building relationships with patients as the foundation of a successful healthcare journey. They are leaders in delivering innovative medical practices and are a certified patient centered medical home.   

Diabetes prevalence has been growing, and people with diabetes are hospitalized at higher rates than non-diabetic individuals. Reducing hospital readmissions has the potential to dramatically reduce overall costs, and more importantly, improve patients’ quality of life. Prior to TCPI, SIM relied on patients to self-report their hospitalizations. Knowing this method provides an incomplete picture, their data analyst created a new data tracking process. They initiated communications with a local hospital system and established a procedure to receive hospitalization data in a timely manner. Now, SIM prioritizes patients who have been hospitalized and follows up to schedule a primary care visit within 48 hours of discharge, a change that reduces the risk for unplanned readmissions.       

SIM is also providing patients with the information they need to better understand and manage their conditions. Patients are given a new education packet with tips and tools for self-management, like a self-testing log they can complete and discuss with their physician. Prior to regularly scheduled appointments, individuals with previously high A1C levels are invited for pre-visit activities to get labs done so their results can inform the appointment. Obtaining this information in advance not only saves the patient time otherwise spent waiting with uncertainty on results after the appointment, but enhances the ability to have meaningful patient-provider conversations and make specific after-visit care management plans.

Taken together, these efforts have reduced readmissions. After starting at a baseline of 7% readmissions for diabetic patients, SIM has consistently held this rate to within a 1-3% range. You can read SIM’s full story here for more details on how they have moved the needle on reducing unplanned hospital admissions.  

Southaven Internal Medicine’s story showcases changes across multiple strategies. They always knew a strong data measurement element would be necessary to implement and sustain these efforts. Often, mastering the data management and EHR integration can be an overwhelming barrier. In the “Practice of Improvement, Part 2” of the MidSouth PTN Best Practices podcast, Dr. Thomas Spain discusses some of these pain points and what we can do to get the most from our data.  

The views expressed in this story are those of the authors and do not necessarily represent the official views of Southaven Internal Medicine. Additionally, this work was funded by the U.S. Department of Health and Human Services – Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiative, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.