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St. Elizabeth Medical Center Reduces Readmissions with Patient Outreach Program

September 10, 2015
by Heather Landi
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St. Elizabeth Medical Center (SEMC) reported significant reductions in its hospital readmissions as the result of a pilot program using a patient outreach solution.

The provider found that patients who engaged with post-discharge follow-up calls were far less likely to be readmitted, with some readmission rates reduced by up to 75 percent.

The medical center, based in Utica, N.Y., is a part of the New York State Delivery System Reform Incentive Payment (DSRIP) program, a reimbursement program from the federal government aimed at care coordination and reducing unnecessary readmissions. SEMC partnered with New York City-based health technology company CipherHealth to use an outreach solution to help reach its DSRIP goal around reducing 30-day readmissions.

As a result of the post-discharge follow-up pilot program, the medical center reported that readmission rates dropped for all four patient populations involved in the pilot: acute myocardial infarction (AMI), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia.

Through the pilot program, which ran from February through June 2015, the medical center used the outreach solution to make three and even up to four follow-up calls to patients post-discharge over a 30-day period.

The medical center found that readmission rates dropped 56 percent for patients who engaged just once with the outreach solution, and for those patients who engaged with all post-charge calls over the 30-day period, the readmission rates were reduced by 75 percent.

Among patients enrolled in the pilot, 80 percent were reached and 45 percent of patients reached required a call back from staff to provide additional support, the medical center reported.

SEMC also leveraged the data provided by the outreach solution to manage patients during the discharge process and, as a result, the rate of post-discharge intervention calls has been reduced since the start of the pilot.

“The implementation of an advanced outreach solution has allowed us to ensure that our patients are staying on track and we can intervene in a timely manner when they need additional support," Kim Witchley, director of social services and care transitions for Mohawk Valley Health System (MVHS), which includes SEMC, said in a statement.

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