Resource Library

2019 Best Practice Awards Submission for Reduction in Utilization

Metro Health committed itself to reduce PCS ED visits for their patient population. Metro Health gave a network-wide, multi-faceted approach to tackle PCS ED visits by carrying open provider panels, creating walk-in appointment slots, conducting extensive marketing of primary care availability, and providing patient education on appropriateness of ED visits. Efforts were also focused to expand their care management program and engage these staff members in ED discharges.

2019 Best Practice Awards Submission for Reduction in Utilization

A Patient Care Navigator contacts high emergency department utilizers using Motivational Interviewing techniques to quickly gain a therapeutic relationship with the patient. Depending on specific diagnosis, the PCN would educate patients on the most appropriate location to receive care, identify and assist with obtaining resources, and support their care plan goals.

2019 Best Practice Awards Submission for Reduction in Utilization

The goal of the program was to include a reduction in utilization by at least five percent as well as an increase in collaboration among care managers across various health organizations. It was a dual effort between LCN and Aetna Better Health to develop a plan for better managing this population. Initially, the focus was on Transition of Care from the inpatient side to either home or long-term care; and in time expanded to manage those frequently utilizing the ED. Collaborative calls allowed for care managers to discuss what barriers may be present, gaps in care, and consulting with outside organizations that may also be interacting with patient. Call time was also used to develop plan for resolution and status/progress reports.

2019 Best Practice Awards Submission for Reduction in Utilization

Case Conferences are a joint effort between inpatient, ambulatory, and community care services that allows for a review of complex patients, communication of challenges and the creation of a consistent care plan. The team consists of a multidisciplinary group with representation from approximately twelve areas. Case Conferences occur monthly with multiple high-utilization patients at each conference. The goal of these Case Conferences is to follow the success of each patient presented and find a reduction in ED utilization and/or readmissions to the hospital, an increase in appointments kept at their ambulatory appointments, as well as favorable changes in other population health metrics.

2019 Best Practice Awards Submission for Reduction in Utilization

Care Management has been an integral part of the practice since 2012, using a team-based approach for maximum effectiveness. The care manager meets with every new patient, explains their role, and provides a business card for future reference. A team approach to managing the care of patients on opioids contributed to a reduction in ED use which has also contributed to a reduction in avoidable inpatient admissions.

2019 Best Practice Awards Winner for Reduction in Utilization

The Whatever It Takes program provides the ability for patients to receive safe treatment at home by community paramedics with support from primary care or emergency department physicians to reduce unnecessary emergency department and inpatient utilization. The initial results from 7/17/2017 to 6/30/2019 were 66% of community paramedic visits resulted in patients being treated at home or transported to an alternate destination.

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.