Grounding the Frequent Fliers

Joe Cantlupe, for HealthLeaders Media , April 15, 2013
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To eliminate gaps in care for diabetic patients, Donahue says, the hospital uses electronic records to identify patients in need of care. While the hospital had tried for years to reduce dangerously high levels of hemoglobin-related blood sugar counts among patients, it recently improved its care in this area, she says.

"They were not getting the care they needed," she says bluntly of diabetic patients. For instance, some patients hadn't checked their hemoglobin levels in six months, says Donahue. In the ED, patients wouldn't know the medications they were on. "We saw an opportunity to identify these patients, get their hemoglobin tested, record their medications, and analyze this information." Continuity from the patients' electronic records coupled with improved care management enabled the hospital to convince patients how important it is to check their hemoglobin levels and maintain improvements in their care.

With dbMotion interoperability software, the hospital has been able to maintain a "master patient index to identify patients between the different EMR systems and consolidate and semantically map the data from across the systems," Donahue says. "We have the data from both hospital and office EMR systems to identify those gaps." Donahue says the hospital's "access to the patient's medication history is greatly improved with access to the [software] and to external medication history through e-prescribing."

Behavioral care and insurers
In Pittsburgh, the proximity of a number of hospitals to each other means that sometimes patients decide that they can take their pick of emergency departments.

A Pennsylvania medical assistance program is seeking to integrate physician and behavioral health services for adults with serious mental illness and physical health comorbidities, directing its efforts at patients who frequent the ED and are often readmitted to the hospitals. Pittsburgh-based UPMC—a $9 billion global health enterprise with 21 hospitals, 400 doctors' offices and outpatient sites, and a health insurance division—is involved in this effort.

Behavioral and physical care systems often lack coordination, which can result in negative impact on individuals, according to James Schuster, MD, MBA, chief medical officer for community care at UPMC's insurance services division.

The program, Connected Care, involves UPMC's Medicaid managed care plan, UPMC for You. From July 2008 through April 2011, the program enlisted more than 2,500 of 8,600 Medicare members in a pilot study. UPMC for You and Community Care Behavioral Health, based in Pittsburgh, launched the test for the Pennsylvania Department of Public Welfare to integrate behavioral and physical healthcare Medicaid services for people with serious mental illness. The organizations worked with other stakeholders, such as behavioral health and physical health systems in Allegheny County, which includes Pittsburgh. By coordinating care and using electronic medical record reviews and case manager follow-up, officials of the UPMC Health Plan say Connected Care has significantly reduced mental health readmissions to hospitals and has shown promise to reduce ED use.

The Connected Care plan involves a multidisciplinary team that holds clinical case reviews for patients with "complex needs." The team, which meets twice a month, includes the health plan's medical directors, care or case managers, clinical supervisors, and UPMC pharmacists. Then UPMC care managers educate the patients on how to manage their physical condition, prevent unnecessary ED visits, and follow up within 24 or 48 hours of a hospital readmission or ED visit.

"The effort required some IT and clinical process development work. This is now complete and the incremental cost for expanding this program to additional regions is expected to be nominal," Schuster says.

The all-cause readmission hospital rate dropped from more than 43% to nearly 39% for the study group from 2007 to 2011, Mathematica Policy Research found. Its report stated that Connected Care "holds promise for improving ED and mental health hospitalization rates." Too often, there are not enough programs to assist patients who simply use the ED as a "kind of urgent care center," says John Lovelace, MS, MSIS, president of government programs and Individual Advantage for the UPMC Health Plan. "Some people don't take advantage of psychiatric care. There is a proportion of people who do not go see a primary care doctor. They don't do anything."

Coordination is impacted by what may seem like the simplest of flaws, Lovelace says. "A lot of times, the ambulatory provider or behavioral health person doesn't know someone was in the ED because the patient doesn't tell them, or they may not see them very often," Lovelace says.

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