Our featured practice this week focuses on care transitions that reduce unnecessary hospital readmissions. By focusing on care management for a specific population, NEA Baptist has reduced readmissions by 54% for patients with congestive heart failure and chronic obstructive pulmonary disease. These phenomenal results speak to the power of targeted care management.
NEA Baptist Clinic is a multi-specialty practice group located in Jonesboro, Arkansas, with more than 100 providers. The clinic is part of Baptist Memorial Health Care, and their integrated health system and dedicated team of providers and administrative support team members promotes a rich culture of continuous quality improvement.
NEA established a new Population Health Management department staffed by nurses to coordinate transitions between primary and specialty care providers. The department’s first focus was to standardized discharge and chronic care management procedures for CHF and COPD patients. NEA used Idea Generation and Kata techniques to engage their frontline providers in creating the discharge outreach protocol. Care coordinators create a clinical risk score for patients who have been hospitalized and contact them within 72 hours of discharge. During this contact, the coordinators review discharge instructions and identify any barriers patients may have to obtaining medications and adhering to their plans.
High risk CHF and COPD patients, regardless of recent hospital admissions, also receive targeted care management. Care coordinators provide weekly follow up calls to monitor and close any gaps in care. Coordinators regularly review patient charts and engage patients in collaborative goal settings. These efforts enhance continuity and help prevent hospital and ED admissions.
This multifaceted approach, bolstered by NEA’s commitment to bold changes as demonstrated through their allocation of resources and staff, has led to reduced admissions far beyond their original goal. After starting with a baseline of 17%, they now maintain an average readmissions rate of 9% for CHF and COPD patients. You can read their full performance story here.
Getting started with care transition protocols can seem overwhelming, especially in large healthcare systems. However, those systems are often the ones that have the most resources to aid in the process. But even small practices can enact quality and process improvement techniques to assist in care transitions. We invite you to listen to Episode 16, “TCPI Expo Care Coordination” With Kirsten Meisinger of the MidSouth PTN Best Practices podcast to learn more about care coordination and care transitions.
The views expressed in this story are those of the authors and do not necessarily represent the official views of NEA Baptist. 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.