Identifying High Utilizers First Step in Reducing Readmissions

Businesses do it all the time — analyze their repeat customers, and market to them, says Susan Horton, DNP, APRN, CHFN, VP of peri-operative services at Central Maine Medical Center and executive director of the Central Maine Heart and Vascular Institute. Healthcare professionals need to take a similar course: analyze their repeat or readmitted customers, in order to ensure they don’t remain so.

First of all, we wanted to know, “Who are our patients?” It sounds like a silly question to ask, and yet none of us could really articulate who were the heart failure patients that were coming back to us. So we spent a fair amount of time looking at our own data. Businesses do that all the time; they know which widgets they buy and what time of the day they buy them, and they market to that. I’m not sure that in healthcare we’re really good about identifying our customer. And more importantly, who is our repeat customer? We really tried to look at that: not only at their age, but the parameters we were seeing in terms of health literacy or social support, as well as the point in their recovery when these patients were coming back.

We are very good as a system, providing as part of our core measure in hospital discharges an appointment for patients when they were discharged home. Most of them have that follow-up appointment with their primary care provider somewhere between day 21 and day 28. But when we really drilled down into our data, we saw that most of our patients were coming back between day 10 and day 14.

We looked at our own hospital claims data to identify anyone that came back for a 30-day readmission. As part of our participation in the Robert Wood Johnson program, we had a template to follow. I needed my quality people and my billing people on board. That was part of that engagement. And that’s what we began to look at.

We reviewed a lot of different literature to determine what was being done in terms of evidence-based guidelines and practice.

Source: New Horizons in Healthcare Home Visits

 New Horizons in Healthcare Home Visits

New Horizons in Healthcare Home Visits profiles two home visit interventions that are helping to reduce hospital readmissions and emergency room visits while enhancing the patient experience in this 30-page special report.

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