Resource Library

2019 Best Practice Awards Submission for Reduction in Utilization

A Care Transitions Team was formed out of Holland Hospital as a means to improve hospital readmission rates for patients discharging with specific diagnoses that put them at highest risk for readmission. This included implementing the Readmission Prevention Solution BOOST tool; providing remote access and training on various systems for medication reconciliation; communicating scope and process to practices; establishing new workflow and documentation standards; developing toolkits, contact lists and other resources; and initiating performance and review meetings.

2019 Best Practice Awards Submission for Reduction in Utilization

An analysis revealed patients' lack of education and understanding, coupled with poor follow-up and self-management skills to be the root cause of readmissions of patients with Congestive Heart Failure. A CHF Registered Nurse Health Navigator was employed to meet identified patients at the bedside and begin the education process. The CHF Health Navigator worked in conjunction with the PCP and Cardiology offices to schedule follow-up appointments prior to discharge and transfer continuing education to the Health Navigator embedded in the PCP office.

2019 Best Practice Awards Submission for Reduction in Utilization

CIPA has been working to engage practice units in implementing and sustaining best practices such as TCM, monitoring ED visits and ADT lists, improving open access scheduling and actively utilizing ED reports. Care managers are being leveraged to monitor high-risk patients, particularly those with chronic conditions, and ED frequent flyers to minimize inappropriate ED Utilization.

2019 Best Practice Awards Submission for Reduction in Utilization

By introducing a tiered/risk-stratified approach to define follow-up, the team was able to right-size staff and approach. By having Population Health Coordinators review and triage each patient, this allowed time to reach more patients with appropriate information and follow-up. This has led to decreased non-emergent ED utilization and percentage of patients without a PCP and increased ED follow-up rates and patients enrolled in longitudinal care management.

2019 Best Practice Awards Submission for Palliative Care

Sylvan Lake Family Practice has developed successful end of life planning processes that include collaboration between the CM, physicians, and office staff in promoting and providing ACP counseling and palliative services; increased office staff awareness and engagement in end of life planning processes; Care Manager led and billed ACP conversations; increased patient satisfaction and peace of mind reported as a result of available end of life planning opportunities; and increased compensation from appropriate billing of codes for ACP services rendered.

2019 Best Practice Awards Submission for HIE/ADT Implementation

Each quarter, Wellcentive reports based on ADT data identify ED utilization by diabetic patients. These reports that also risk-stratify patients are sent to care managers in the six pilot practices. The reports are used to aid to the care managers to identify patients (high ED utilizers and high-risk diabetics) who would benefit from care management interventions. Care manager workflow includes addressing gaps in care, improved care coordination, addressing SDoH needs, establishing self-management goals to improve patient outcomes and reduce healthcare costs, and address appropriate use of ED.

2019 Best Practice Awards Winner for HIE/ADT Implementation

As part of this project, OSP launched an alert and notification tool organization-wide informing care managers and providers of Admissions, Discharges, and Transfers; developed and introduced standardized care coordination activities supported by ADT messages promoting Transitions of Care; and targeted PDCM engagement strategy and care model redesign based on ADT notification and TOC.

2019 Best Practice Awards Submission for HIE/ADT Implementation

OPNS has been publishing Admit, Discharge, and Transfer notifications for over four years to its physicians and continues to improve on the quality of message delivery to physicians to utilize the data available. OPNS was recognized as a Qualified Organization in Fall 2017 with MiHIN and started receiving ADT messages directly. Messages through MiHIN are near real-time, and OPNS physicians no longer have to wait 36-48 hours to receive messages to complete necessary follow-up. OPNS has seen positive changes in ER admissions/readmissions as a result of utilizing the ADT reports.

2019 Best Practice Awards Submission for HIE/ADT Implementation

The goal was to automate data flow containing valuable quality and Admission Discharge Transfer data for all patients. In order to accomplish this goal, the identified need was to develop a process by using a reliable Health Information Exchange system that could send data from the ambulatory Electronic Medical Record, Athena. The HIE/ADT Implementation took place in 2016 to 2017. Goals have been met to capture all the data elements needed and transmit the data through an automated process. The ADT information has also greatly improved identification of patients utilizing ED and IP services in real time.

2019 Best Practice Awards Submission for HIE/ADT Implementation

Through the use of Carespective, the MAG secure provider portal, practice embedded care managers accessed and used the ADT notices to follow patients who have been discharged from an inpatient, emergency department, or other encounter at a hospital facility. The practice care managers' access to real time ADT notices and follow-up with patients after a facility encounter has resulted in an overall decrease in ER visits, a decrease in inpatient readmissions, and a decrease in frequent ER utilization.