Not only must organizations create sophisticated business intelligence tools to help identify high-risk patients, providers will have to engage patients and provide better care coordination to reduce readmissions, said IT industry leaders who participated in a panel that tackled care management and the medical home at the Healthcare Informatics Executive Summit in Orlando in May.

“If we’re going to crack this whole issue of readmissions, plus so many other deficiencies, we need better processes, better outcomes, and a sustainable process, which is what cost [reduction] is really all about, then we’re going to have to solve these problems. It’s not just decreasing readmissions,” said James L. “Larry” Holly, M.D., CEO, Southeast Texas Medical Associates (SETMA), LLP, a participant on the “Beyond the Data Warehouse: Strategizing the Use and Analysis of Clinical Data for Meaningful Use” panel. “That’s what the medical home is all about, redefining processes, improving outcomes, and doing it in a sustainable fashion.”


Larry Holly, M.D.

Since 2009, the Beaumont, Texas-based SETMA has had more than 12,000 patients discharged, with 98.7 percent of those patients having received a hospital care summary and treatment plan document upon discharge. SETMA’s detailed care summary has a list of the medications the patient should be taking and the patient’s follow-up appointments with the name, address, and phone number of the physician.

Sam VanNorman, director of business intelligence, Park Nicollet Health System, an integrated healthcare system located in St. Louis Park, Minn., said that his system has, based on patient feedback, incorporated graphics like maps to the physician offices and images of what medications look like into its discharge care plans. “Just asking the patients, what would make this useful to you” is important, VanNorman said. “First off, you’re asking them, which is the big engager, number one. Second, you’re giving them something they can use.” He added that his system has also distributed bus passes and prepaid cell phones to improve follow-up care for patients, by enhancing their compliance with care management.


Sam VanNorman

Care Coordination Competencies
Beyond care summary documents, many healthcare systems and health plans across the country are beefing up care coordination competencies like follow-up calls and visits. “We realized we desperately needed further contact with the patients outside of the classic settings, but where there is not an economic exchange taking place,” said SETMA’s Holly, “so we established a care coaching call which takes place the day after the patient leaves the hospital. The key is empowering and enabling that patient to take charge of their care. If they’re not engaged, you’re going to have a hard time.”

SETMA patients receive a 12- to 30-minute call the day after they are discharged, to provide follow-up coaching. If the patient is at high risk for readmission, then care coordinators ensure the patient is seen by their primary care provider within three days; and all discharged patients, regardless of risk level, are seen within six days.


The 14-hospital, Arlington, Tex.-based Texas Health Resources (THR) is taking its post acute discharge care plan a step further. Not only does the health system make post discharge follow-up calls, a group of providers make house calls to the highest-risk patients and document their encounters in THR’s electronic health record (EHR). “We’re also sending those at highest risk home with remote patient monitoring, so we’re actually capturing their vital signs remotely and having telehealth interactions with those patients,” said Ferdinand Velasco, M.D., chief health information officer at THR.


Ferdinand Velasco, M.D.

Beyond care coordination, all three discussion panel participants said their organizations were executing sophisticated data analytics using business intelligence software to identify high-risk patients for readmissions.

“That’s been a collaborative activity with a researcher at Parkland,” said Velasco. “He’s developed a very sophisticated risk prediction model looking not just at clinical risk factors, but socio-economic status and other data that are captured in the EHR, and using this prediction model to give a more fine-tuned assessment of patients. We’re working with him to better direct intensive risk-reduction efforts to those patients that are at highest risk.”

Velasco said that THR’s predictive models are not only focusing on morbidities and co-morbidities, but zip code, how many times the patient has moved, how many relatives the patient has for social support, and all things that are documented as a byproduct of care in the EHR to stratify the risk and to target the most at-risk patients. Through these efforts, THR has been able to reduce heart failure patient readmission rates by 25 percent.

Velasco admitted that readmission rates are just the tip of the iceberg and really a lagging indicator of bad care coordination; and that there’s much more, like the entire measure of access to care, that goes into reducing readmissions. He lamented the fact that most commercial EHRs lack the functionality to assess and predict readmissions and urged healthcare organizations to develop these competencies independently through various programs.