Taking a Population Health Approach
The Safe Transitions program represents a shift in healthcare. Hospitals are realizing that they are responsible for the patient even after discharge, says Kelly Luther, URMC's director of social work and patient and family services.
"The biggest challenge is actually shifting the culture from one focused on episodes of care to one based on population management," she says. "We are so used to taking care of what is in front of us at this very moment and then faxing that piece of paper and hoping all goes well at the next place where that patient is received."
Redesigning the care continuum around new ways to care for populations is critical to URMC's ability to prevent readmissions and to make gains on other quality measures, Berliant says.
"One of the markers of quality of care is readmissions, but that is just one marker. We are also looking at overall admission rates, ED visits, and other areas," he says. "What is clear is we are trying to evolve toward a population health model of care delivery… It all goes hand-in-hand if we are going to be paid for quality and not just for volume."
Identifying High-Risk Patients
URMC has embedded a risk stratification tool in its electronic health record to identify patients with the highest risk of readmission so that these patients can receive additional attention after discharge, Luther says.
"You can capture some real success this way in terms of preventing a readmission," she says. "For example, during a follow-up phone call, if a patient says they are not going to take their meds until they see their own doctor, then that is an opportunity where the case manager can offer some clarification about how and why to take their meds."
Smarter use of the EHR has also helped URMC work more effectively with its local skilled nursing facilities to prevent readmissions, Luther adds.