STAGE 7 SPOTLIGHT TriHealth: Reducing SNF Readmissions

HIMSS Analytics

Formed as a partnership between Good Samaritan Hospital and Bethesda Hospital, Inc, TriHealth now encompasses 4 acute-care hospitals totaling over 900 beds, 1 short-stay surgical hospital, 2 freestanding ambulatory surgery centers, 140 outpatient locations, 150 physician practice locations and more than 600 employed physicians. Their mission is to improve the health status of the people they serve by providing a full range of health-related services including preventative maintenance, wellness and education.

The Challenge

TriHealth sought a solution for tracking and monitoring quality and utilization in post-acute care settings, including skilled nursing facilities (SNF) and home care (HC) to develop a preferred provider network that was based on objective data. They needed a system for healthcare data reporting and documentation throughout the effort to ensure a longitudinal view of the patient across the care continuum by disease (cardiac, orthopedic, pulmonary, wound, infectious disease, and other). That's where the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM) comes into play.

Implementation Overview

Every SNF and HC organization within the health system had the opportunity to participate in the programs. New systems and data collection methods were implemented, leading to:

  • The creation of an association process of the patient to the SNF and Home Care Agency at discharge. This helped put them on the care team, allowing TriHealth to limit patient access for each of these facilities to only their patients.
  • Remote access for each facility to log into TriHealth’s instance of Epic. Once logged in, their first screen is a Workbench Report showing only the patients associated to them.
  • Patient selection from this custom list presented caregivers with flowsheets that allow the agency to access discrete document metrics.
  • Healthcare data reporting was used to to demonstrate how well agencies performed against one another related to quality outcomes. Key participants included Senior Services Team Members, IT security, IT report writers, IT Senior Analyst, Lead Application Analyst, Physician and Executive Leadership, Legal, Physician Hospital Organization, inpatient care management, Health Network Solution, and marketing teams. The team worked to gain similar data insight from 80 Skilled Nursing Facilities and 25 Home Care companies.

Resulting Value / ROI

By harnessing healthcare data reporting and developing the tracking of data within EPIC for our post-acute providers, TriHealth was able to:

  • Monitor performance in post-acute settings to develop a preferred provider network.
  • Outperform national post-acute cost-of-care averages by over $300.
  • Achieve a lower length of stay, lower readmission rate, and lower total cost of care in skilled nursing care for Comprehensive Care for Joint Replacement (CJR) patients between April 2016 and June 2017.
  • Track doctor’s appointments made prior to patient discharge from the SNF. Over the past year they have seen an increased awareness and compliance in the SNF scheduling appointments, from 50.4% to 62% in 2017.
  • Educate patients about the value of the network through our 4-page education tool based on objective measures.
  • Reduce SNF readmissions, length of stay, and total cost of care as reported through Centers for Medicare & Medicaid Services (CMS) data provided by the Health Solutions Network (HSN- TriHealth collaboration with St. Elizabeth Hospital) and CJR claims data.
  • Discharge more new medicare patients to SNF preferred providers.

Lessons Learned

The core of TriHealth's success in achieving Stage 7 was their data communication effort. System maintenance and improvement was also key — system users meet monthly to find solutions together and improve processes, and monthly measurement reports are distributed to the entire network to improve care and optimize the system. TriHealth's collaborative training and on-boarding also contributed to the network's optimization.

By explaining the 'why' of the EPIC implementation to the entire network team, TriHealth demonstrated the true value of the SNF Preferred Provider Network and involved all stakeholders in the network's decision-making process to achieve strong results.

Like TriHealth, healthcare organizations around the world can use the HIMSS Analytics EMRAM to improve the quality, efficiency and cost of healthcare.

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