Tag Archives: readmissions

Intalere Member Best Practice Spotlight – Coastal Connect Health Information Exchange – CABG Patient Care Intervention for Improved Patient Outcomes


In August 2017, three heart surgeons reached out to Coastal Connect Health Information Exchange (CCHIE) and requested real-time, electronic notifications for their Coronary Artery Bypass Grafting (CABG) patients that admit to the hospital emergency department to support timely care intervention in an effort to reduce preventable hospital readmissions.


CCHIE’s electronic alerting tool, NOTIFY, allows subscribers to receive a text message or email notification on encounter types: emergency room admission, emergency room discharge, inpatient admission, inpatient discharge, re-admission and death. The NOTIFY tool is powered by ADT (Admission, Discharge and Transfer) feeds CCHIE has established with stakeholder hospitals and alerts care team members on patient encounters to drive timely clinician engagement for care transition. CABG patient names are loaded into the NOTIFY system; at 31 days, patients are removed from the list. When a patient on the list admits to the hospital emergency department, the NOTIFY tool sends an electronic, real-time alert to two surgical navigators that initiate intervention by the heart surgeons while the CABG patient is in the emergency room.


Since loading the initial CABG patient list in September 2017, 53 notifications of CABG patient admissions to the emergency room have been sent to surgical care navigators resulting in readmission avoidance. The stakeholder hospital’s Readmission Team met in November and confirmed the real-time notifications CCHIE delivered in the first two months resulted in timely patient intervention, preventing readmission for two patients, resulting in a savings of more than $26,000 using the average cost for a CABG readmission. Additional benefits of utilizing the NOTIFY tool include improved outcomes and experiences for the patient, improved workflow and more impactful use of resources for the care team.

 About Coastal Connect Health Information Exchange

Coastal Connect Health Information Exchange was established in 2009 by provider stakeholders to securely connect unaffiliated healthcare providers in southeastern North Carolina for electronic, real-time, at-the-point-of-care sharing of patient care information to support patient-centric care transition between providers, reduce redundant testing and realize efficiency in workflow.

Check out the project video and view the CCHIE page in the 2018 Intalere Best Practices Compendium.

Intalere Member Best Practice Spotlight-Milford Regional Medical Center-Redefining Traditional Roles to Reduce Readmissions


The senior management team and board of trustees of Milford Regional Medical Center identified reducing avoidable readmissions as a hospital-wide goal. Although certain diagnoses contribute to the bulk of readmissions, Milford Regional identified medication, discharge planning, patient and family engagement, and social issues (transportation and nutrition) as key areas affecting readmissions.


The facility implemented the High Risk Mobile Team (HRMT) program, an unconventional and progressive approach to reducing readmissions, focusing on repairing gaps in the support structure for patients as they transition from hospital to home. At the hospital, an HRMT member meets with the patient and anticipates potential post-discharge needs. A colleague is then assigned to the case, participating in daily huddles with case managers and social workers to determine modifications upon discharge to prevent a readmission. Another team member will visit the patient at home, allowing them to identify and address barriers to medication, insurance coverage or basic needs. The pharmacist educates the patient on medication and dosage, and if needed, collaborates with the physician or the pharmaceutical manufacturer for an affordable medication so the patient receives the optimal treatment.


The efforts of the HRMT have shown a trend in reduction of avoidable readmissions over the past year. These efforts have also led to a reduction in the facility’s CMS readmission penalty patient population, thus potentially reducing readmission penalties. The HRMT has received accolades from patients and families for the care that is provided.


Milford Regional Medical Center is a comprehensive healthcare facility located at the intersection of Routes 140 and 16 in Milford, Mass. A full-service, community and regional teaching hospital, Milford Regional is a 145-bed, non-profit, acute care facility, serving a region of 20+ towns.

View the Milford Regional Medical Center page in the 2017 Intalere Best Practices Compendium.

Nutrition in the Changing Healthcare Landscape

peter cayan

by Peter Cayan, MA, RD, CDN, LDN

Senior Director, Nutrition Specialists, Intalere

Nutrition and nutrition therapy have never been more relevant than now in the age of healthcare reform and the changing healthcare landscape. I recently discussed this topic with Dr. Tracy Smith, senior clinical manager for Abbott Nutrition, for a podcast.

According to the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) no longer pays for hospital-acquired conditions such as pressure ulcers, falls and hospital-acquired infections – all of which have strong connections to malnutrition. Malnutrition increases the risk of hospital-acquired conditions and readmissions and can also delay recovery, increase medical complications and extend length of stay – all of which contribute to escalating costs. By identifying and treating malnourished patients upon admission and through discharge, hospitals can significantly improve quality and patient outcomes while reducing costs and meeting healthcare reform provisions.

People entering the hospital with poor nutrition status have poorer outcomes than their nourished peers. Nutrition status often worsens in the hospital, and may not improve on discharge unless the patient is given a post-discharge nutrition plan. The prevention and treatment of hospital malnutrition offer a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes and reduce costs.

The interdisciplinary Alliance to Advance Patient Nutrition was formed to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition.

The alliance has developed a call to action regarding the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. Empowerment of all clinicians, recognition and diagnosis of all patients, same-day automatic intervention for all at-risk patients, education and involvement of patients in their nutrition care, and appreciation of the value of nutrition by all hospital stakeholders is absolutely critical. The alliance plan features a quality improvement program (QIP), which includes an initial screening for risk of malnutrition, communication plans for rapid intervention for those judged at risk and finally, a discharge plan that includes nutritional care.

Several studies have been done recently investigating the effect of implementing a QIP on reducing non-elective 30-day readmissions and healthcare costs for hospitalized patients identified as malnourished. The authors concluded that 30-day non-elective hospital readmissions and healthcare costs from avoided readmissions can be significantly decreased, while hospital and patient savings can be improved among the malnourished inpatient population through a rapid, comprehensive QIP.

To learn more about the importance of nutritional care in the current healthcare environment and plans for early nutrition intervention, listen to our podcast and/or read the transcript.

Intalere Member Best Practice Spotlight-Northern Arizona Healthcare/Flagstaff Medical Center-Reduction of Hospital Readmissions for Patients with Previously Identified Malnutrition


Malnutrition is a serious issue, with 1 in 3 U.S. hospital patients being affected. The Centers for Medicare and Medicaid Services (CMS) have projected reduced reimbursement for malnutrition readmissions within 30 days of discharge. At Flagstaff Medical Center (FMC), 42% of patients identified at risk for malnutrition were being readmitted within 30 days of discharge.


An evidence-based intervention study was implemented to identify strategies to minimize the number of patients readmitted due to malnutrition. Malnutrition education was implemented, including development of a “Malnutrition Guide” which was reviewed with all inpatient staff and providers. A “Malnutrition Protocol” was established for early identification, diagnosis, treatment and discharge planning to reduce 30-day hospital readmissions.


The Malnutrition Protocol for discharge management and the prevention of readmissions resulted in a reduction of length of stay for this population and a reduction of readmission days. In a 12-month study, cost savings of $76,417 for a 101.89 reduction in hospital days and prevention of 23 patient readmissions was realized. The malnutrition readmission rate was reduced from 42% to 9.89%.


Flagstaff Medical Center (FMC), a member of Northern Arizona Healthcare, is a full-service, 267-bed, Level 1 Trauma Center facility. FMC has approximately 2,000 employees and more than 200 physicians on its active medical staff. FMC’s mission is to improve the health of the people and communities it serves.

Check out the project video and view FMC’s page in the 2016 Intalere Best Practices Compendium.




Intalere Member Best Practice Spotlight: Crossing Rivers Health Navigating the C’s – Collaboration, Coordination and Continuity – to Reduce Readmissions

Crossing River Health

This post looks at how the implementation of an interdisciplinary readmission team at Crossing Rivers Health in Wisconsin helped dramatically reduce readmission rates.


Crossing Rivers Health was missing the consistency necessary to sustain a reduction in readmission rates. The facility’s goal was to enhance collaboration, coordination and continuity related to patient care transitions.


An interdisciplinary readmissions team was established to conduct an in-depth analysis of current processes and protocols to develop systems to close any identified gaps, and Lean principles were used to map out processes. The team integrated best practices to create a sustainable and replicable process to benefit all patients. A Nurse Navigator program was implemented which enhanced identification of moderate and high-risk patients, coordinated care after discharge and provided follow up with a home visit when needed. Follow-up phone calls within 24 hours of discharge and consistent patient education were also emphasized.


Crossing Rivers Health’s readmission rate for December 2013 was 12 percent. After implementing the Nurse Navigator program and evidence-based strategies, the average 2014 readmission rate was 7.5 percent. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for “Staff discussed needs after discharge” in 2013 was 90.5 percent and was 98.6 percent the last quarter of 2014. These innovative strategies provide a seamless transition process for the patients.

About Crossing Rivers Health

Crossing Rivers Health (CRH), a non-profit, 25-bed Critical Access Hospital, was established in 1957. CRH serves approximately 300 people per day and employs more than 330 healthcare professionals. CRH provides more than 60 services which fulfill the healthcare needs of the people across southwest Wisconsin and northeast Iowa.

Read more member success stories here to learn more best practices for your healthcare organization.

Achieving Population Health Management

Photo - Todd Ebert 100x150

By Todd Ebert, President and CEO, Intalere

If you were to ask 10 different people to define Population Health Management (PHM), you might get 10 different answers. To put it simply, PHM means healthcare providers are responsible for caring for the health outcomes of defined groups (or populations) of patients. Physicians can no longer dwell in the mindset of caring only for individual patients in their waiting rooms, hospitals no longer with just people in their beds. It’s not just about the sick in this new era of reform.

The new models provide interventions to address patterns of morbidity, reduce costs and help people stay well. The focus is on minimizing chronic conditions and less episodic care. The objective is to keep everyone healthy, and to do that requires healthcare providers to pay close attention to defined populations and coordinate their care. Trends will include community coalitions, narrow networks taking patients through the continuum of care and evidence-based payment models.

At the recent Intalere Executive Forum, Intalere members and industry leaders gathered to discuss key elements of population health management and to review current successes by Intalere members Virginia Mason Medical Center, OSF Healthcare, Intermountain Healthcare and Samaritan Health Services.

All of these organizations have had success implementing programs that feature these important competencies:

  • –  Care automation
  • –  Care coordination
  • –  Reduction in readmissions
  • –  Cost and utilization measurement across the continuum of care
  • –  Improved patient compliance, no-show rates and engagement
  • –  Quality measure reporting
  • –  Patient stratification and interventions targeted to the right people and populations
  • –  Outreach and quality patient education
  • –  Connectivity to community-based organizations

All of this does take enormous time and money, but despite the costs, the incentives surrounding the inevitability of value-driven healthcare are too powerful to ignore. The future of healthcare will be what population health management is all about – the healthcare provider utilizing the right people and right resources, including technology, to provide better organized, more personalized and proactive care to all patients.

To learn more about key components and best practices in achieving PHM, download Intalere’s latest briefing, Keys to Achieving Population Health Management.