As hospitals prepare for reimbursement changes that will penalize high readmission rates, University of Michigan Hospitals and Health Centers set its sights on high utilizers of the emergency department and hospital services to reduce readmissions.
The healthcare organization targeted a care management program on frequent flier patients with psychosocial needs, which had a team of nurse care managers, social work care managers and non-clinical patient care associates follow-up with low-complexity patients at discharge and offer ongoing intensive care management for complicated or challenging patients, according to an article from AHC Media.
Thanks to the care management program, overall readmissions fell from 20 percent to 17.4 percent.
Unlike traditional disease management programs, the hospital's intensive care management program acknowledges that frequent fliers may not have resources available to manage their medical and non-medical conditions.
"The care managers can provide important education and help meet the patient's non-medical needs," said Brent Williams, medical director of complex care management at the University of Michigan Ann Arbor Medical Center. They also can give physicians additional information about the patients' social or financial circumstances.
The intensive care management program reinforces care coordination, as the care manager and the primary care physician both meet with the patient to develop a care management plan.
Similar models are taking hold in New Jersey, where healthcare organizations are teaming up to connect high-cost, high-need Medicaid, Medicare and uninsured patients with intensive care management, according to the Daily Disruption. The groups expect to save $67.7 million over three years by enhancing access to ambulatory medical and social services, improving patient outcomes and curbing avoidable hospital and emergency department use.