Episode 64: Reducing Readmissions One Patient at a Time

Heather: This is BACON, brief ACO News from the MaineHealth Accountable Care Organization. A monthly podcast for healthcare providers. I'm Heather Ward and I'm Mike Clark.

Mike: Heather and I are practicing physicians and participants in the MaineHealth ACO. This month, we'll learn about a promising readmission reduction collaboration between the ACO and St. Mary's Hospital in Lewiston.

Heather: Okay, let's get to it. This month marks the one-year anniversary of a project that our two guests created together. Johanna Rawson is the director of care coordination at St. Mary's Hospital, and Danielle Scott is the MaineHealth ACO's manager of complex care. Welcome to you both.

Danielle: Thank you.

Johanna: Thank you.

Mike: This is very interesting. I'm curious to hear about what you've learned. And I thought it might be useful to kind of get a little bit of the backstory. This initiative is focused on reducing 30-day hospital readmissions. Johanna, what's kind of the context for that? How common are readmissions at St. Mary's or what was the problem that you were solving?

Johanna: The problem, along with St. Mary's but also with all health systems, is payer reimbursement. The payment structure has changed in that if you have a patient who is readmitted, it could be all cause/reasons, it doesn't matter; it doesn't have to be the same problem that they were discharged with and readmitted for the same problem. We are not getting paid for that second admission. That was hugely significant. We needed to have a concerted effort to help partner with our outpatient practices and providers to make sure that patients were being seen closely for follow up, that if there are any continuing care needs, that those are being addressed so that patients don't present back in the hospital. And we can do interventions on an outpatient basis, which will prevent an admission.

Heather: Very important work. Danielle, I'm curious to know what brought you and Johanna together to tackle this lofty goal of readmissions.

Danielle: I was working on my capstone for my master's degree in nursing around this time last year, my final project, and I was really interested in transitions of care, and at that same point, was simultaneously investigating or researching St. Mary's transitional care process. My interest really stemmed from my experience as a care manager and knowing that the transition from hospital to home can easily result in patients falling through the cracks.

Mike: Absolutely.

Danielle: Med errors, particularly, are a really big culprit. And that summer, Johanna had just started working for St. Mary's and executive leadership had introduced us and said, hey, you guys should really know each other. Johanna had invited me to the St. Mary's Internal Readmissions workgroup. Basically, she was telling me about her previous position. They had a huddle where they would discuss readmissions. We just decided to work together on a proposal and a workflow.

Danielle: You know, I do, from my experience, know that patients are really overwhelmed, especially the complex ones, when they leave the hospital. They need help navigating this really complicated system. My interest was just really stemming from the patients that we care for. And for care management, you know, saw it as a great opportunity to get good referrals for patients when they're in a very vulnerable state to really help them navigate and reinforce instructions, making ensure that they are cared for during that process.

Mike: Kind of introduce us to this in practice, how does the intervention that you have developed together, how did this sort of, this little nugget of an idea blossom into an actual intervention?

Danielle: Johanna, it was originally your idea. We just kind of molded it to what we have available within our teams. So do you want to start by talking about your former process?

Johanna: Yeah. Very much a community-based team that we were in, we were part of an ACO. Inpatient and outpatient were managed under the same hospital system. So, it wasn't a separate ACO, we were we're all together with that. We would see patients who come in with complex medical needs, usually they would have some sort of home health intervention involved, a lot of times there was a behavioral health component to them. And because of part of the ACO, we needed to capture certain metrics to show that we were looking at the high risk, higher risk, low risk, moderate risk patients and doing interventions for those. I said, well, I'm not going to learn another system to log into and document on. But what I can do is host and facilitate a meeting and keep track of who I'm seeing coming in here. So that's what I did on my end.

Johanna: We had our local home health agency, our mental health agency leads for the case managers, and the practices. It was really more of leadership who is having these conversations. And I would generate the list, and I would send it out to these care teams so they could talk to their partners or research cases. And then we would talk about what are the different interventions that we think that each of us could offer to help keep this patient successfully out of the hospital. What kinds of interventions can we do?

Johanna: I would start a plan A and a plan B in the hospital. I'd ask my team please have a plan B for people. Yes. They don't want to go to a skilled nursing. That's fine. However please secure them a bed and then I can hand it off to be like hey, home health, we're having PT these social work services in there. They had a bed at Berlin before they decided to go home. Let's just get them under their 30 day benefit or whatever into that facility, therefore bypassing another hospitalization.

Johanna: And then I talked to Danielle about that. And we said, well, how can we partner with our patients, like who meets criteria to participate in the MaineHealth ACO? And then how do we talk about those patients here? How do we make sure that the components that need to be followed up on are being followed up on and who does what? As we have higher needs patients, everybody's trying to engage them. But sometimes that can be really confusing for the patient receiving all these phone calls. They don't know who they're calling from. It's everybody's got similar and ish titles. How do we really make it all right. Home health. You're the point person until this point. And then we're going to readdress that. Then we're going to pass it off to the case manager and the practice so that we're not duplicating work and we're not confusing patients.

Heather: That sounds amazing. I just want to take a moment to summarize what I hear you saying, if that's okay. And then maybe we could have Danielle jump in and talk about the current iteration. What I hear you saying is you're looking at complex patients with complex needs. You're pulling together a group of people that's like a complex group to address these needs. You're looking at it from the hospital stay, transition to outpatient, understanding what the patient needs as far as interventions, and then who does what. I think that's like such a such an important part. I totally agree. Patients just get confused. That's really exciting. Danielle how does that translate right now?

Danielle: I just want to put it out there that we're not just discussing what makes this huddle. We have a huddle every Monday. What makes it sort of unique is we're not just discussing what the patient needs at discharge, we're actually anticipating needs post-discharge as well. We have Andwell Home Health, so we have a liaison. His name is Shane from Andwell Home Health, who attends this meeting on Monday. Nikki, who is a St. Mary's discharge nurse case manager who's on Johanna's team. Ashley Goodwin she is the director of primary care with St. Mary's. Jenn Bonn, she's a MHACO care manager who assists St. Mary's with transitions of care, and then myself and Johanna. And then we will sometimes invite people in, like care managers who may be working with patients on my team for additional expertise. If we have a very complicated patient. It's a huddle that every Monday, Johanna sends the list out the week before of discharges. We get together on Monday and we share resources and essentially develop a plan of care and make sure that we have all of those connection points needed in order to care for the patient beyond discharge.

Heather: Yeah. This sounds fantastic. I'm wondering if you could make it a little bit more real for us and give us a bit of a case study.

Danielle: I'm going to talk about a patient who we'll call Bob. And he was our very first patient. Johanna and I. Johanna, you probably remember him?

Johanna: Oh, yes.

Danielle: We still talk about him on occasion. He started out the year last year, so we're talking about 2023, with four readmits and has only had one within, so he's only had one within the last seven months, and that was in July. Bob's ED and hospitalizations together cost a total of $80,000. And actually had this looked up by our MHACO Analytics Team. He had seven ED visits and eight admissions total for 2023, and they were all mostly due to his complications with congestive heart failure. And as you know, it's a very complex disease for somebody to manage on their own. Johanna and I knew that we had to enroll him. Johanna had brought him up several times. He was admitted in December, and I think he had had several admissions prior to that, but was admitted in. Johanna actually called me on the phone and said, can Sarah Ranger, one of our ACO care managers, come down to the hospital and meet him in the hospital? Because this guy is impossible to engage. We just can't get through to this this guy, and he's definitely going to need something beyond discharge in order to prevent another readmission. We weren't really optimistic that this would work out because like I said, others had tried and had a really difficult time convincing him, but we gave it a shot anyway. And so Sarah went down there. Sarah just worked her magic and was able to befriend Bob and keep that connection after he was discharged. I would say that with care management, it takes several months in order to build that trust. Some people longer than others, but Sarah and Liz Fowler, our social worker was involved as well, were able to convince him that he needed support.

Danielle: When he was admitted, we would work through as a team; Johanna's team and Home Health to ensure we had a plan and that we were all on the same page. And the biggest thing that he needed really was Maximus Assessment. He was a very lonely guy; he had trouble caring for himself in the home. He had a daughter, but, you know, she was minimally involved and didn't really want to be involved. And it was very complicated just to get that done. It actually took several months because I don't know if you, you know, know anything about Maximus Assessment, but there's all these rules and regulations around it. It can't be done in the hospital. It can't be done by care management, can't order it if the patient is in Home Health, and every time the patient is readmitted, it resets the whole process. And he was just consistently being admitted. So it was really difficult to get that going. But once we finally did, we were able to go through the process of finding placement for him and then convincing him that he would be in a better place. When all was said and done, and this actually happened recently, he was placed. I think the big win was when Liz Fowler, the social worker, said to me the other day that he called her and said, "I have never had so many friends. I am just I'm so happy to be here and, you know, have all these friends and companions and people I can talk to." And so that was really a big win. You know, Sarah and Liz continued to still be involved with him because he is complex. I consider him a definite success.

Mike: Wow. That's great. It's so isn't it so compelling when we, you know, although we are talking about, you know, cost reduction, right? And addressing utilization issues that are so critical. In the end, we center the patient and it's just, wow, this is about doing the right thing for our patients and making it, not just from our perspective but from his. His life has changed by this intervention and a personal way so compelling. And a huge reduction in hospitalizations in ER visits to boot. I'm curious, you know, as these programs go, you work together, you've assembled this crackerjack team of people, and you kind of have this cadence of working together. Have there been any sort of changes or evolutions or lessons learned as you have rolled this project forward over the past few months?

Johanna: Lessons learned from my previous experience, and what I'm trying to share here is, it's important to have a whole care team of people and to have a conversation, and from my perspective, to say "what's going to engage this patient." Because simply making a phone call, which is what was happening before with Bob. He's like whatever a phone call. That's why I was like, hey, can Sarah come over and see him in person? Because those warm handoff, those introductions and previous times when Bob came in, Liz Fowler, the social worker, we had, you know, getting long term MaineCare and she would physically come see him here in the hospital. And it made for a whole care team that supported Bob. You know, what feels like the hospital side of things, because he would see us more frequently than he would see his primary care provider, and identifying who is the point person that's going to be able to engage this patient, and how do we best engage them so that we can do the interventions that will meet their needs?

Heather: This program has been running for a year now. I'm really curious to know what kind of outcome data you might have.

Johanna: This is Johanna. I can speak to Saint Mary's. The last six months, our readmission rate has reduced by 50%, a little more than 50%. In March we were at 15%, and now for September statistics were 7.14%. And that's for all cause readmissions. Danielle?

Danielle: For MHACO attributed St. Mary's primary care patients, we've enrolled 70 patients in care management since the beginning of the program. In the first three months, we had of the program, we had 7 30-day readmits. In the last six months, we've only had one readmit.

Mike: This is both impressive statistically as well as heartwarming personally. This is such important work. Again, I love the nexus of data, cost reduction, and patient centered care. You guys have done great work. Thank you so much for bringing it to our podcast today. It was great to have you here.

Danielle: Thank you.

Johanna: Thank you.

Heather: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's Bacon@mainehealth.org.

Mike: BACON is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. We will see you next time.

Heather: See you next time.