Data and measuresThe Health Index initiative tracks and monitors a variety of data sources to measure progress being made to decrease preventable hospitalizations.
One metric often used to monitor potentially preventable hospitalizations is the rate of admissions for ambulatory care-sensitive conditions (ACSC). For these health issues, high-quality outpatient care often can avoid hospitalizations, or early intervention can prevent complications or more severe disease.
The ACSC hospitalization rate in the MaineHealth service area decreased from 2013 to 2014, progressing toward the long-term target rate of 30 or less in 2019 as MaineHealth continues to coordinate patient and family centered care provided by collaborative, integrated teams.
Within the MaineHealth Accountable Care Organization (MHACO), the hospitalization rates for COPD/asthma decreased over the past year and are currently below the short-term target rate of 8.3 or less set for fiscal year 2018. After a temporary increase in the hospitalization rates for heart failure (over three reporting periods) the rate for January to December 2016 was lower than the baseline rate of 12.6 in fiscal year 2015.
Taking action: Providing team-based, coordinated care
We support a variety of clinical, community and policy actions to help decrease preventable hospitalizations throughout the MaineHealth service area. Preventing unnecessary hospitalizations is a critical strategy for reducing cost of care while increasing the efficiency of health systems.
The Patient-Centered Medical Home (PCMH) is a team-based model of providing care in a coordinated, consistent and efficient way. This approach helps clinicians manage chronic health conditions in a more proactive fashion and access specialists thus reducing unnecessary emergency room visits and admissions.
MaineHealth has a goal that all member-owned primary care practices will attain PCMH Level III NCQA recognition by September 30, 2017. However, not all inpatient admissions can be avoided and once a patient has received inpatient treatment it is important to receive appropriate outpatient treatment to prevent readmission.
As part of the strategy to reduce readmissions, a key strategy is the use of the Transitions of Care Bundle for all patients being discharged. The bundle includes risk assessment, medication reconciliation, timely communication between hospital and outpatient providers and patient education.