UVA Health Tackles Readmissions with Medicine HOME Program

Amber Inofuentes, M.D.: I'll tell the origin story, so to speak. Initially this program began as part of a readmission reduction effort by the medical subspecialty service line at UVA. At that time, I was a medical director on one of our medical units and one of our partner units. And the former section head of Hospital Medicine, Dr. Helgerson began looking at all readmissions from a single Medicine Unit—all 30-day readmissions—and they really were looking at what were the root causes to try to figure out what they could do from a quality improvement perspective. And interestingly, what they found was, in addition to some root causes about why readmissions might occur, they also found that there was this occurrence that patients, young adult patients, with sickle cell disease were being readmitted very frequently. So, there was this signal around patients with sickle cell disease.

At that time, I was looped into that work to be one of the hospitalists involved. Additionally, there was a group of frontline nurses, physicians, social workers, case managers, and a whole team around that unit, who decided to look very deliberately at this population of patients who were admitted frequently, and we ended up having a guest speaker from Duke, Dr. Joanna Kipnis. She did rounds for us and talked about a program that you could develop to focus on sickle cell patients with high hospital utilization. That program implemented individualized care plans and has published that work. They were willing to share some of their work with us, their templates, and how they began their work.

And so out of that, we began meeting with 10 patients. There were 10 patients who were identified in this population and accounted for about a million dollars in annual costs, as well as about 7 percent of all the 30-day readmissions from internal medicine. So, they're a very huge percentage with a really tiny population. We began meeting with each of these patients to try to understand from them things like what works well when you come into the hospital or what doesn't work well. What kind of care is good or not and then we also pulled together a team of hematologists, palliative care physicians who help with pain management, social work, etc. to create individualized care plans—or what we call ICPs for these patients, and then we would publish those in our electronic medical record so that any team, whether you're in the clinic or hospital or ER, can see them and use them with the goal of making sure that every time a patient comes in with a presentation of their illness, they get consistent, high-quality care.

At the end of our first year doing this, the summer of 2018, we analyzed our data and saw that we had had about a 65 percent reduction in 30-day readmissions, and about a 40 to 50 percent reduction in that pilot population and admissions and bed days of care. And that then led us to negotiate for funding and formalizing the program and that's when we became the HOME program. The fall of 2018 is when we were able to advocate for full time nurse in Theresa, so that's when she joined the program. And as we establish a formal program with funding, it really allowed us to also say that we're going to expand beyond just patients with sickle cell and really look at any adult patient who is hospitalized frequently, regardless of their underlying primary diagnosis. We then started enrolling one to two patients a month with really any underlying diagnosis and have been going at that ever since.

Can you share some technical details?

Teresa Radford, R.N.: Many of our patients with complex conditions experience quality-of-life challenges such as unstable living conditions, food insecurity, lack of transportation, etc. These patients are also among the most frequent users of the ED—often at multiple locations across the state. We needed a way to extend access to each patient’s ICP to ED providers outside of UVA Health.

We began partnering with the CommonWealth’s Emergency Department Care Coordination (EDCC) program using technology provided by PointClickCare to alert our Medicine HOME Program care coordination team whenever an enrolled patient seeks care at any ED in Virginia. PointClickCare’s solution integrates with our EHR and leverages ADT feeds and expansive care collaboration network to push notifications to clinicians at the point of care. When a Medicine HOME patient arrives in an ED, for example, real-time alerts built into the network notify the case manager at the start of the visit. The care coordination team is then able to supply the treating physician with the patient’s ICP to ensure optimal care and treatment. We’re always trying to break down barriers to care and care silos—especially when treating our most vulnerable patients. Our work with PointClickCare and the EDCC supports a highly informed and highly coordinated approach that improves care and reduces costs for patients with complex conditions. 

For example, in one recent case, our team received an alert that a Medicine HOME patient diagnosed with end-stage renal disease and experiencing homelessness had arrived in another health system’s ED. We were able to reach out to that ED to notify them of this patient’s housing status and request for transition to a skilled nursing facility.  We were also able to direct them to the patient’s individual care plan, leading to a better outcome for the patient.

Was it hard to get support, financial or otherwise, from the board or leadership for this program?

Inofuentes: In 2016-2017, readmissions were such a hot button item for all healthcare systems—the implementation of readmissions penalties and the Affordable Care Act. There was just a lot of attention and focus on that, and I think that really made it very easy to leverage what we were focusing on as a way to address some of the readmission issues. I think we had a lot of buy in because we were well aligned with priorities of the health system. I don't recall negotiating for the program with the health system and the medical center being challenging at that time. I think that as we've expanded, that readmission focus no longer really exists as much in healthcare systems as it did several years ago. In the grand scheme of budgets and penalties, the readmission penalty is relatively small to a hospital's operating budget.

And now the focus, and the priority, is more in the space of patient progression as it relates to “our hospital is super full.” Many hospitals are super full all the time. So, how can our program improve the ability to prevent people being hospitalized who don't necessarily need to be? And allow those in who maybe really need to be hospitalized? I don't think we're as easily able to say now, like we prevent readmissions, you should give us more resources so we can take care of more patients. And so, I think we have to say it's made us think a little bit more about how we demonstrate that we're not just reducing utilization, and that we're actually improving the quality of care for patients. We're improving physician and nurse satisfaction, especially the satisfaction of our care team in taking care of a complex needs’ population. How do we help reduce the burden on a primary care clinic and caring for really complex patients? I do think that the way we frame our value has changed and we're still learning how to do that well. But a year ago, we came under [the] population health [department] at UVA. And that has been tremendously helpful because that's all about population health. This is what they [the population health department] do, they demonstrate their value based on care of a population. I think we've had a lot of success in that space because of the strong population health program UVA has, particularly with its leadership.

Radford: I would say one of the challenges wasn't a financial barrier for me, but more of a cultural one. There are quite a few silos in the institution, like in most institutions, between home health and what a patient is receiving at home, or in the clinic, or in acute care. And conceptually, it was a little bit hard for some people to understand how important it was to follow the patient where they were, rather than having the patient come to us, especially with this population. Tearing down those silos and following the patients wherever they are was a really important factor in meeting patient needs and being successful in what we were doing.

How are patients receiving this program?

Radford: The majority of patients have been very, very receptive and appreciative. It's a different model of care, so it does kind of take getting used to. Yesterday, for example, I met with someone at McDonald's because they have insecure housing. Then today, I was with them in their clinic with their primary care doctor. This is a new relationship I'm developing with this particular patient, trying to build that trusting relationship, whether it's in the hospital or in the home or in the emergency room or on the street, to me is really important. Patients and families are usually very receptive to working with you, not to say it's easy or perfect, especially when one of the things you'll be doing for some patients is to actually streamline or restrict some of the medication management that they might be getting—restricting opioids or things like that. Most of the time in that situation a patient can really be uncomfortable and not particularly want your help. But if you're building that trusting relationship, I have found you often can get past that it's just a little bit difficult at first.

Inofuentes: Some of what we've learned over the past five years, and I've learned this now in talking with some other programs, is that we aren't entirely unique. There are patients for whom this program is not a good fit for, and they generally have the same thing in common. For example, one person said that staying out of the hospital wasn’t an issue for him and the number of times he was in the hospital wasn’t an issue. He felt as though he was sick and coming when he needed it. We saw it as a problem, and he didn't. I think if you detect if that's the case, then I don't think the program is going to be a good fit. If you're not aligned around a common goal of helping a patient improve their quality of life and health and doing that more out of the hospital than in the hospital, then you're not going to necessarily have a partner in what we're trying to accomplish together.