By diving deep into existing data, officials at John C. Lincoln Network accountable care organization (ACO) realized the primary cause of readmissions for a subset of patients wasn’t inaccessible primary care, but lack of food. Patients were going to the emergency room on Friday evenings because they didn’t have food to last the weekend; Meals on Wheels only ran Mondays through Fridays, said Heather Jelonek, chief operating officer for accountable care organizations.
We did a lot of work prior to launching our Transition Coach Program in 2012. We studied 69 patients who had been readmitted into our hospitals within 30 days following heart attack, heart failure and pneumonia. What we found in common was that every one of those patients had hit our emergency room (ER) department.
So we started developing strategies: building urgent care clinics, immediate care clinics, and extending our primary care office hours to make sure we were available when our patients needed the care. We saw somewhat of a reduction in our readmission rates based on that program alone, so we took another deep dive. We found more congestive heart failures (CHF) specifically, and 85 percent of our patients who were readmitted within 30 days were also Meals on Wheels beneficiaries. In our area, Meals on Wheels only runs Monday through Friday. These patients were presenting on a Friday evening because they didn’t have food to last them through the weekend. They’d come in, get their food, and be taken care of; Monday they would be discharged and Meals on Wheels would start all over again.
Through our relationship with Desert Mission Food Bank, we’ve been able to connect these patients with what we call our Snack Pack Programs. Desert Mission drops off backpacks full of nutritious and healthy food that will carry the patient and any family members in the patient’s home through the weekend. We have seen, again, a drastic reduction in hospital readmissions.
Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care describeS the sources combed by the John C. Lincoln ACO addressed operational and technological challenges during the pre-launch period, and how these efforts and resulting data enhanced quality measurement and reporting.