Risk-Stratification Can Lead to Decrease in Readmissions

Wednesday, July 20th, 2011
This post was written by Jackie Lyons

By risk-stratifying patients at high risk for hospitalizations and re-hospitalizations into a coordinated, multi-disciplinarian program, HealthCare Partners Medical Group of California has significantly reduced readmissions for its patients, reports Dr. Stuart Levine, MHA, corporate medical director for HealthCare Partners Medical Group.

Targeting high-risk patients can be difficult but necessary, explained Levine during the recent webinar Reducing Readmissions Through Multi-Disciplinary Post-Discharge Support. The HealthCare Partners Medical Group risk-stratification program is driven by type of disease, complexity of disease and ROI. By utilizing a predictive modeling tool to separate the patient’s conditions into hierarchical categories, the patients are placed into the medical home that best suits their needs.

The medical homes are separated into hospice and palliative care, home care, an end-stage renal disease (ESRD) medical home program, comprehensive care centers and post-discharge clinics. A significant amount of the care is telephonic, with intermittent face-to-face care, and patients with specific diseases have home monitoring devices as well.

According to Dr. Levine, the patient delivery system is based on health education, prevention and chronic-care management for most patients. Risk-stratification pays off for the patient and the provider during patient discharge and handoff. On a daily basis, there are coordination calls between all of the high-risk patients, the hospitals and other high-risk practitioners, as well as between the primary doctors and location to which the patient is discharged.

The specialists act as consultants, oftentimes going on-site to the clinics to practice their specialty care to ensure the handoff between primary care and specialty care is efficient, Levine explained. Listen to an interview with Dr. Levine.

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