The Affordable Care Act requires the Centers for Medicare & Medicaid Services to penalize hospitals for preventable readmissions. But Parkland Health and Hospital System was focused on readmissions years before this readmission reduction program began. Ruben Amarasingham, MD, MBA, has long believed in using technology to improve care for vulnerable populations. As founder, president, and CEO of PCCI – Parkland’s nonprofit affiliate – Amarasingham, along with his PCCI team, turned this belief into reality by developing an electronic medical record (EMR)–based model to predict readmissions. The model has successfully reduced readmissions and hospital costs, positioning Parkland as a leader in the use of predictive modeling to improve health care.

“As an attending physician at Parkland in 2007, one of my tasks was to manually review charts of patients readmitted within 30 days,” Amarasingham says. “I believed there was a way to automate this process in order to predict which patients were at risk before they left the hospital.” As a result, Amarasingham developed the Pieces™ software system, which extracts data from the hospital EMR system to predict a patient’s risk of readmission in real time.

The Intervention

Focusing initially on heart failure (HF), PCCI team members developed an automated HF readmission prediction model, run by Pieces™, which uses 29 clinical, social, behavioral, and utilization factors to calculate an HF patient’s risk for readmission. Pieces™ automatically extracts data for HF patients within 24 hours of admission – a critical window of time for intervention – and calculates their risk of readmission. In addition to avoiding the time-consuming, imprecise manual review process, Pieces™ accelerates the intervention timeline and enables case managers to direct their limited resources appropriately. “Providing a uniform, high-intensity care transition program often requires a depth of case management resources out of reach for many institutions, particularly those that serve large volumes of vulnerable patients,” explains Elizabeth Dwelle, PhD, communications and media manager of PCCI. “This targeted approach for delivering interventions is evidence-based and effective in reducing readmissions.”

Once a patient is targeted as high-risk, Parkland applies well-known inpatient and outpatient counseling and monitoring strategies to reduce readmissions, including the following:

  • detailed inpatient clinical assessment, patient coaching, and discharge planning by an HF nurse practitioner, pharmacist, nutritionist, and case manager, starting early in the hospital course
  • follow-up nurse phone call within 48 hours of discharge to assess whether the patient obtained medication and is aware of outpatient follow-up appointments
  • outpatient case management for 30 days
  • cardiology appointment with an HF specialist within seven days of discharge and a subsequent cardiology follow-up roughly one month later
  • primary care appointment, scheduled according to the urgency of noncardiac problems

Nurses work with family members to understand patients’ potential barriers to follow-up care and educate them about HF, symptom management, dietary restrictions, and medications. Nurses also arrange for social services, such as transportation to and from appointments.

While the intervention alone provided the clinical tools for success, a coordinated communication strategy built support for the program across the organization, including the leadership team. This top-level support led to several key policy changes that enhanced the program’s effectiveness:

  • Participating patients are not charged a copayment up front.
  • Standing order sets – developed cross-departmentally – ensure consistent, coordinated care.
  • High-risk patients receive a red identification card signaling priority status when scheduling appointments or filling prescriptions.

A detailed media communications plan generated significant external publicity for the program and helped position Parkland and PCCI as industry leaders. Media attention included articles in outlets such as KERA (the public media outlet for north Texas), D Healthcare Daily, and Health Affairs and peer-reviewed journals such as Medical Care. Amarasingham has also given more than 20 in-person presentations.

The Results

During the 12-month period following implementation, Pieces™ targeted 228 HF patients, or 24.9 percent of 913 HF admissions. As a result, the 30-day, all-cause readmission rate for patients initially admitted to Parkland for HF dropped from 26.2 percent to 21.2 percent (a 19 percent relative reduction). A subgroup analysis of Medicare patients demonstrated a 9.4 percent drop (a 31 percent relative reduction). It is important to note that this rate includes readmissions to any hospital in the Dallas-Fort Worth metroplex (Parkland is in Dallas).

The readmissions reduction saved Parkland an estimated $500,000 during the time period. And while the hospital is still working on a formal cost-effectiveness analysis, staff predict sustained and even augmented cost-savings in subsequent years, as the readmission rate has continued to decline. In fact, the hospital’s readmission penalty rate for fiscal year 2013 was 0.03 percent, versus the national safety net hospital average of 0.33 percent. “This program achieved significant reduction in readmissions without increasing staff, except for a part-time case manager at 25 percent effort to assist with high-risk HF patients,” Dwelle says. “This is an extremely valuable feat for a safety net hospital.”

These results, in combination with the coordinated media push, have caught the health care industry’s attention and identified Parkland as a model for success with payment and delivery reform. PCCI has fielded inquiries about Pieces™ from more than 250 hospitals. And in 2011, PCCI received a $2 million grant from the Gordon and Betty Moore Foundation to help with program implementation in three additional hospitals. Internally, PCCI has expanded the program to include high-risk patients with acute myocardial infarction, pneumonia, and diabetes mellitus, and created www.pccipieces.org, which provides information on all of PCCI’s work.

For more information about Pieces™ and the associated quality improvement intervention, please contact:

Elizabeth Dwelle, PhD
Communications and Media Manager
PCCI
elizabeth.dwelle@phhs.org
214-590-4339