STAGE 7 SPOTLIGHT Santa Clara Valley Medical Center: Reducing Readmission Rates

HIMSS Analytics

Over the past decade, HIMSS Analytics has developed and standardized several maturity models for healthcare optimization. The most well-known and widespread of these models, the Electronic Medical Record Adoption Model (EMRAM), measures the adoption and implementation of EMR systems within healthcare organizations.

The EMRAM provides guidelines for healthcare organizations and their use of EMRs to increase operational efficiency, reduce costs and improve patient outcomes. Let's examine those benefits in action with the Stage 7 EMRAM validation of Santa Clara Medical Valley Center.

The Challenge

Located in San Jose, California, Santa Clara Valley Medical Center (SCVMC) has been an integral part of the public healthcare delivery system in Santa Clara County for over 140 years. SCVMC is nationally recognized and is accredited by The Joint Commission. Additionally, the Burn Center, Rehabilitation Center, Cancer Center, Emergency Department, Trauma and Stroke Programs have all been accredited by The Joint Commission or verified by the American College of Surgeons and/or the American Burn Association.

SCVMC is comprised of a 574-bed acute care hospital and 11 health facilities, including primary care clinics, located throughout Santa Clara County. Regional specialty services provided by SCVMC include women’s and children’s health, labor and delivery, neonatology, and pediatrics. It is a safety net health system that cares for a substantial population of Medicaid (in California, known as Medi-Cal) patients.

SCVMC needed to improve patient care and increase revenue from SCVMC Medi-Cal patients. Medi-Cal offers substantial incentives for healthcare providers to meet specific performance metrics. Three Medi-Cal metrics tied to the incentives (worth $5.4 million) relate to reducing readmission rates. To earn payments, SCVMC had to reduce the readmission rate by a full 1% in one year. This was ambitious, because SCVMC was already very close to the national average. In order to accomplish this goal, they needed to create robust improvement plans, including a plan to enhance tools and the use of tools, so the providers could use the right metrics to inform and aid in patient care.

The EMRAM Implementation

Dashboards and Metrics

SCVMC used a variety of Epic electronic medical record tools to provide readily accessible metrics and to inform the development of performance improvement plans. At the leadership level, a dashboard provided comprehensive views of metrics, including readmission rates. Leadership could view metrics on the clinic and provider level, and evaluate monthly trends. Using this information, the organization was able to make data-based decisions and could work with providers and locations to improve performance and address any disparities they noticed in the dashboard.

Care Coordination

Care teams worked to address the full scope of why readmissions occur, acknowledging that healthcare needs to address challenging social situations that occur outside of the hospital in order to reduce readmissions. SCVMC started by hiring a team of nurses to focus on this effort. Before a patient would be fully discharged, a nurse would provide resources such as an outpatient care coordinator, transportation and recommended substance abuse treatment options. Prior to discharge, the team would work with the patient to identify gaps in care, to communicate with the primary care team and to address as many identifiable gaps as possible. Post discharge, nurses would continue to follow up with patients with outreach tracking tools.

Complexity Scoring

It quickly became obvious that the nurses didn’t have the capacity to provide this level of attention to every discharged patient. To help the nurses regain capacity, the team was instructed to target their efforts on the patients who have a higher risk of readmission. The Chief Medical Information Officer’s (CMIO) team created a score for evaluating a patient’s level of risk. The rating system combined clinical and social factors such as preferred language, history of substance abuse and homelessness. The modified Epic General Risk Score was provided to inpatient nurses and primary care physicians, so they could focus their efforts on the patients in their schedule that required more attention.

The Results

The effort to reduce hospital readmissions improves outcomes for people with Medicare by linking hospital payments to the quality of the care provided, rather than quantifying services provided in a given performance period.

By improving the quality of care provided and extending it through a patient’s transition to discharge, SCVMC was able to reduce readmissions by the goal of 1% and met all three Medi-Cal readmission metrics, which earned the hospital $5.4 million.

The Takeaway

SCVMC found that using the EMR in an innovative way to share information and provide continuity of care works and that when metrics were easy to read and understand, the staff was better able to make improvements in care.

For SCVMC to meet their goal of reducing readmissions by 1% they needed to focus on improving discharge plans and providing resource education. Following up with discharged patients was critical. Lacking in resources, SCVMC used a modified complexity score to target efforts toward the patients most at risk of readmission.

Ultimately, SCVMC realized that a combination of tools were needed to reach their goal. They needed to use metrics to inform in-patient care and post-discharge care coordination, including communication between providers, partners, patients and caregivers.

By using data and electronic medical records, the team was able to better coordinate transitions of care and reduce readmission rates for an important population of under-served patients.

Like SCVMC, healthcare organizations can use the EMRAM to drive technology transformation and healthcare optimization in their facilities. By maximizing the tools available within the EMR system, healthcare organizations can improve the security of private health data, the efficiency and cost of diagnosis and treatment, and the overall health outcomes of their patients.

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