Hospital Cuts Readmissions With Focus On Primary Care

Software links emergency department patients with follow-up care to cut nonessential return trips to the hospital.

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A Missouri hospital has been able to cut inpatient readmissions by a third, mostly by improving communication between its emergency department (ED) and area clinics. The plan: make sure patients have primary care physicians for follow up and only come back to the ED for true medical emergencies.

Cox Medical Center Branson (Mo.), formerly known as Skaggs Regional Medical Center until Springfield, Mo., based CoxHealth took over at the beginning of the year, augmented its embrace of the patient-centered medical home model with software to match patients with primary care physicians and to identify ED "frequent fliers" and others at high risk for readmission. "We're trying to get them to establish a relationship with a provider," explained Michael Elley, Cox Branson CIO and VP of support services.

Cox Branson is somewhat small, with 165 licensed beds, but, befitting its location in a tourist magnet, has 40,000 ED visits annually, with heavy traffic during the summer months. Four out of five inpatient admissions come through the ED, according to Amy Swanson, IT clinical analyst and project manager of the implementation of Care Continuity, a software-as-a-service application from T-System, a Dallas-based electronic health records (EHR) vendor specializing in ED information systems.

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According to T-System, the technology lets ED personnel send an email or text message to each patient's primary care physician at various times during an ED visit or inpatient stay, with links to a secure portal containing medical records and test results. Before discharging a patient, the hospital sends a referral request to a primary care doctor, who then can accept by setting up an appointment, or decline. If a physician declines, the ED tries to match the patient with another provider to make sure the individual receives proper follow-up care.

Cox Branson employs physicians at 19 affiliated clinics, all of which have access to the T-System platform through the Web. "We are working out how to roll it out to independent practices," Swanson said.

Elley said 9% of the population in the hospital's service area is uninsured, and staff at Cox Branson tries hard to connect discharged uninsured patients with primary care physicians. "We don't want them using the ER or even urgent care for primary care," he said.

"There should not be an open-ended discharge of the patient to the curbside," T-System CEO Sunny Sanyal emphasized.

Sanyal said the Care Continuity app produces discharge instructions for each patient. Cox Branson currently prints the notes, though the software does have the ability to transmit the notes electronically, which is one way providers can meet a requirement in the Stage 2 Meaningful Use standards that 50% of patients have the ability to view their own health information online.

Cox Branson already has achieved Stage 1 Meaningful Use with a McKesson inpatient EHR and has a patient portal supplied by Beaverton, Ore.-based Kryptiq, Elley said, though the hospital will be migrating to CoxHealth's Cerner EHR.

The Care Continuity system flags high-risk patients who might need special attention and identifies people upon their third visit to the ED so the hospital can make it a priority to find primary care for them. It also helps the hospital determine why patients are being readmitted or why they are coming to the ED instead of visiting a primary care physician or a dentist or a behavioral health professional, Swanson said.

Cox Branson had a soft launch of Care Continuity in late November but a full rollout in January. "In the first two months, we were able to connect 400 people to primary care physicians who didn't have one before," Elley reported.

In 2012, the hospital had an overall 30-day readmission rate of 9%, according to Elley, below what he said was the statewide average of 11%-12%, but that dropped from 11.5% in January 2012 to 7.7% by the end of the year after the focus on primary care began. (The Dartmouth Atlas of Health Care reported that in 2009 the national average readmission rate among Medicare beneficiaries was 16.1% overall and 12.7% for surgical patients.)

This is particularly important for Cox Branson because the hospital derives 65% of its patients and 59% of revenue from Medicare, according to statistics provided to InformationWeek Healthcare. That federal program for Americans 65 and older no longer reimburses hospitals for preventable 30-day readmissions of patients treated for heart attacks, heart failure or pneumonia. Elley said Cox Branson is worse than the national average for all three of those conditions.

"We want to be judged on quality," Elley said.

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