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Today on Town Hall

our COPD readmission rates were at 23.03%.

We've reduced those to 13.3%. Pneumonia went from 10.45% to 3.9, so, being able to look at those readmissions and find out why they keep readmitting has been very helpful.

My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health.

Where we are dedicated to transforming healthcare, one connection at a time. Our town hall show is designed to bring insights from practitioners and leaders. on the front lines of healthcare.

Alright, let's jump right into today's episode.

Hello and thanks for joining us on this episode of Town Hall. I'm Brett Oliver, a family physician and the Chief Medical Information Officer for Baptist Health in Kentucky and Indiana, and I'm pleased to welcome Carrie McHenry to the show. Carrie is the Care Transition Manager with Independence Health and Clarion Hospital.

Carrie, welcome.

Welcome, thank you.

Yeah, absolutely. If you don't mind, start off just kind of tell us a little bit about Independence Health and Clarion Hospital.

Independence Health Systems comprised now of Butler Memorial Hospital, Clarion, Frick, Latrobe, and Westmoreland Hospitals with a combined bed total of 925. more than 1, 000 physicians and advanced practice providers, 7, 300 employees, the system is the third largest in western Pennsylvania.

serving a population base of over 750, 000 with a footprint spanning for more than 10 counties. The system includes tertiary programs rated amongst America's best cardiac care and surgery, and it's earning accolades for a number of prestigious outlets and organizations. They're locally owned and operated and controlled and independence health systems.

They've tried to Provide low cost, high quality care across the care system, so.

Fantastic. Fantastic. So a lot of rural areas, it sounds like. A lot

of rural, yes. As

well. Excellent. So now you guys recently received a pretty significant clinical champion award for your care coordination program. Can you tell a little bit more about that recognition?

That transition plan, we really wanted to take people from illness care to wellness care. And what we meant by that was we really wanted to provide our patients with basic needs and resources. Many of the patients that were being seen through our ER were treating the ER as their family physician.

So, it was really about just breaking that cycle and, changing their mindset. The first step involved changing that mindset. The next step involved addressing those needs so they weren't repeatedly coming back into the hospital. The goals that we addressed by, by doing that were we identified some social determinants of health barriers as well as potentially avoidable utilization admitting patients.

Excellent. So clearly it's thriving at this point. Both before and then you accelerated it. What was the initial catalyst behind developing it?

Was it that readmission rate using the ER kind of as that first line of defense? Were there any other? Issues that you guys saw that were behind developing the program itself.

Sure the client hospital developed a community needs assessment where pinpointed areas of concerns and needs within the community.

this report summarized the comprehensiveness in a review of they analyze the information. In the community to what the needs were, the economic, demographic, and other quantitative and qualitative data from primary service areas of Clarion Hospital. They really took that information and identified the health needs and issues of the community itself in the primary service area of the hospital.

The Community Health Needs Assessment provided useful information for public health and health care providers, policymakers, social service agencies, community groups, and the like. The results enabled the hospital, as well as other community providers, to provide more of a strategic catalyst, so to speak, to be able to provide those resources for the community.

Through analysis of local rural community, revealed that approximately 40 percent of the readmissions were due to COPD and pneumonia, and that community needs assessment also revealed that 52 percent of the county residents lived below that poverty level. So, it was really important to identify what those needs were not just to look at the readmission rates, but also to look at what those needs were so that we could figure out why they kept coming back to the hospital the impact of the social determinants of health for the community in those conditions that provided supports to the individuals that allowed us to do that.

to ask a variety of different questions for them to determine what those needs were. When I first started, we were only looking at five areas of the social determinants of health. We were looking at food, transportation, utilities and housing. Shortly after I started, we started looking at other things because those five things were Looking into other areas that we could help.

So we added other areas with mental health and substance abuse. We added disability supports, community and family supports, and then financial support. So those are the other 5 questions that we started asking, and it really allowed us to hone in on what those reasons were. Why couldn't they afford housing?

Was it for financial reasons? Was it for mental health or substance abuse reasons? So it really just kind of helped us. Hone in on those first five and redevelop those next ones. We later decided to add CHF and diabetes using our community needs assessment. We really wanted to just help as many patients as possible through the hospital system.

We looked at many different diagnoses and determined that by adding the CHF and diabetes, it allowed us to focus on those that were readmitted repeatedly and also allowed us to continue support through the hospital system. So we determined that CHF and diabetes individuals were more at high risk to return to the hospital and needed those additional supports.

Probably a lot of crossover, too, with your pneumonia patients having diabetes or heart failure that led to some of that as well. Well, let's get practical here. So, tell me a little bit about the program in the sense that readmission reduction is one of your goals. So, once someone goes home from the hospital, what are those steps that you guys follow with patients?

Sure. Once they go home I'm following them at day seven. Once they're discharged, and then I follow them again at 90 days. The seven day follow up call is primarily just to make sure that they have the discharge reports from the hospital, they understand all of the information that was given to them.

I'm asking them, do they have their follow up appointments met or scheduled. If they don't have them scheduled, I'm helping them schedule those follow up appointments. But I'm also asking them, if I haven't already asked them, I'm asking them those questions related to the social determinants of health.

And then from there, I take that information, I call them again at 30 days, 60 days, and then 90 days. Through that 90 day period, I'm really just kind of looking at what their needs are and helping them with supports that they need, whether it be housing, transportation food.

Linking them up with services in the community through local churches, local organizations, non profits. Those kinds of things. For those individuals that have other needs like food insecurities or other health related issues that need more education, we're referring them to the food program, which is through Butler Health Systems and our Independence Health System.

They have a food pantry. where with the food program that they can get up to so many meals for a few months at a time, and then they get also get the education provided to them. Lifestyle coaching program provides education and services regarding diabetes, COPD, CHF, pneumonia. They do pulmonary rehab as well.

So we just kind of take all of that information together and make sure that they have all of the resources that they need.

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Did you use an outside resource that gathered that for you and kind of keeps it up to date? I think one of the challenges that folks in these kind of programs find, especially in the more rural areas where I've practiced, is there's a food pantry until there's not, or, it's not a guarantee that it's there.

And how do you guys keep that resource list up to date?

I utilize findhelp. org and then the PA 211. Consistently a lot that has the, they update their systems pretty regularly. So that information is on there, but I've lived and worked in this community my entire life. So I know people, I know organizations, so I'm able to like keep that registry going.

The local churches, the, the nonprofit organizations, the I know who can help and where they can help and what those funding sources are. So it makes it kind of an added advantage for Cling Hospital. Not to toot my own horn or anything. No. Yeah, you're the wild

card in it. That's fantastic.

Yeah.

Being in, being from the community is very helpful 'cause I know a lot of people and resources.

That makes a lot of sense. All right, so we talk a lot about technology on this podcast, as you can imagine. In your care transition management program, how are you leveraging technology, whether it's to track or follow up with patients, SDOH needs that we've been talking about?

Where's technology fit in?

Well, when I first started our informatics team developed through the Meditech and Expanse system, they developed the ability for me to be able to track the SDOH needs through the health related screening needs tool, and that allowed me to, I could enter a patient, I could put why they were admitted, their index reason for being admitted.

I could put, did they leave the hospital with home health, or did they refuse? Any of those SDOH needs were also on there. From there, I wasn't able, though, to get any of the reports that I needed. I wasn't able to, you know, Really hone in on what people really needed as far as a database. So we kind of made our own homegrown system.

We used a spreadsheet. Again, that spreadsheet wasn't allowing us to track certain things, especially the readmissions. So, our informatics team, along with people from Meditech and Expanse, and then an outside company, they developed a tracking through the business analytics systems. that allows me, anybody that I'm putting into that SDOH or the health related screening needs tool, that tracking system in Meditech and Expanse, that pulls all of that information out.

So I can track by patient. I can pull off reports that how many times this patient has been at the hospital, how many times That patient has been here for food or other insecurities. I can track by diagnosis. I can track by insurance. Kind of, it gives me a whole variety of ways that I'm able to track those.

The greatest thing that, that we were able to do with that is I'm really able to track how many people that we're serving. To date, we have 534 individuals that we've supported through the Care Navigation Program. Some of those, I believe it's like 146 of those individuals are repeats, but those repeated ones are individuals, maybe they just needed a little extra support, maybe they just need Connected with other like waiver type programs or community support.

But for the majority of those 534 that we've supported, some of them don't need any supports, but I'd say probably about 33 percent of those individuals we've supported through finding them resources in the community SDOH needs.

Does that technology allow you, at the time the patient's discharged, so the physician that discharges them from the hospital, does that referral then go straight to you, or are you picking up a queue of names that are discharged with certain diagnosis?

Is there an interplay there?

Typically what I do is once they're admitted to the hospital, I look at their chart. If they have a previous diagnosis of COPD, CHF, diabetes, or pneumonia, I'm looking at that the diabetes and the pneumonia are a little bit more difficult because the diabetes if it's type 1, I'm picking them up automatically.

If it's type 2, I'm really looking at what other diagnosis and what brought them in to begin with. Is it health style needs that they have or is it, lack of food or education? So, those two really just determines, What their basic needs are and then in talking with the patients but primarily it's just going through the Meditech and Expanse system, looking at their records and then talking with the rest of the team here to ensure, who gets chosen to be supported.

Sometimes the doctors are telling us, hey, they've got some needs so they need supported. So, anyone who's admitted is getting an SDOH assessment completed. The nurses are asking them that on admission, so that's another resource for me , I receive that in every morning those supports.

They're automatically printed to my computer, so I get them every morning. Any of those that have a positive indicator needing supports, I'm automatically looking at those.

Yeah, that's great. And then, is there a connection then, I know you mentioned earlier on that a lot of these folks are using the.

Emergency room as their primary care physician. I have to ask as a primary care physician, is the access just that big of a deal in some of these communities where there is no one for them? Or is there an attempt as part of what you guys do in terms of supporting them to try to get them connected?

Or how does that?

Yeah, most of them have

primary care positions. They're just not using them.

Right. And we have found that the majority of them, they've utilized care physicians in the past, they've had people, but they stopped going because of transportation, they stopped going because of, other health related needs that they couldn't get there.

So it was reconnecting them, if it was, they were receiving supports from a primary 20 miles away, trying to connect them with someone maybe that's, That's a little closer, you know, five miles away, setting them up with transportation, setting them up with other community support so that their health needs are being met so that they can make it to those appointments.

Yeah. Makes a lot of sense.

Well, so I got to believe you guys have had some good results, obviously you had the champion award, et cetera, but what are some of the results since you launched the program? Yeah. Absolutely.

Since that we've reduced those to 13.3%. The pneumonia went from 10.45% to 3.9, and then our overall 30 day readmissions has decreased from 13% to just a little under 11%. So, being able to look at those readmissions and track them and find out why they keep readmitting has been very helpful.

Yeah, absolutely.

Well, in that, what are the challenges that you found? Maybe with the program, is it resource availability? Like, we could do so much more if there were more resources or identifying the right patients. We still haven't got that dialed in like I'd like to. What are the challenges you see moving forward?

Challenges moving forward just really trying to, because we are so rural, trying to make sure that everybody has all of the resources that they need really trying to make sure that people know what resources are available to them and not just if there's an issue, they go to the hospital. Making sure that they understand You know, that communication between the hospital and the doctor's offices.

The hospital utilizes hospitalists through the system itself now. So the majority of their primary care physicians aren't coming into the hospital anymore. So it's that communication between the hospital and their physicians, but it's also setting them up with those resources. The biggest challenge, because we are so rural, is that transportation piece.

Because we are so rural, we have a local transportation bus that will take them around the local community. We have county transportation, but we'll only take them to medical appointments. So it's connecting them with local churches or other providers that will provide taxi vouchers so that they can get to Walmart to buy groceries, so that they can get to the local riverside, those kinds of things.

But as far as challenges, really, it's just, it's the communication and trying to, Make sure that they are, they're aware of what those resources are. One of the biggest challenges that I found is if I'm waiting until they're discharged and I'm calling them on the phone, there's still a bit of a disconnect, so I'm really trying to, while they're here at the hospital, connect with them so that they're seeing a face to face person so that when I call them and I say, Hey, this is Carrie, you talk to me at the hospital.

They've already got that connection and they seem to feel more comfortable talking with me about what those needs are. Some individuals are still apprehensive about opening up to what they need, but by seeing my face prior to discharge, they're at least able to recognize me as a person and not just another phone call.

Yeah, absolutely. The trust that you establish seeing them in the hospital. I love that. And I would imagine that you could play the card of, I'm from here, Yeah, I live here. I'm not from a bigger community. I just come in to do this job. I having practice in a rural community for the first year. I was here years ago.

I got a lot of you live and mentioned the bigger city. That's nearby. You probably live down there. I know I live right here and I didn't understand. I was too young and naive to understand that. partner that I joined was like, you, the only requirement I have is that you live in this county. And I was like, well, that's what I plan on doing anyway, but I didn't realize the impact that you're alluding to of being there.

Not just knowing the resources, but I think the trust factor that then gets them to answer the phone that drops that veil of pride that says, I don't need any help when they don't have any way to get to the pharmacy or they can't afford their medicine or what have you. So that's fantastic.

Yeah.

So what's next?

What's the vision for the future for the program? I'm sure you got. Other things that you'd love to take on?

We do. We are looking at other areas. Independence Health Systems has secured a behavior specialist, so that behavior specialist will be able to make referrals to her or as needed through the physician's offices.

We'll be able to utilize that for more mental health and substance abuse supports. Other things that we're looking at is Taking a look at other diagnoses that can be supported through the hospital system. Also looking at utilizing our services through the ER a little bit more than what we have.

Not really looking at any of those individuals unless they're readmitted. I do look at ER reports on a daily basis, but I'm primarily looking for those individuals that are already being supported by the program or have been supported in the past. So by looking at the, Individuals in the ER and supporting the staff that are downstairs.

We can hopefully eliminate some more of those SDOH needs, since they're not being admitted to the hospital. They can connect them with some resources there. The other thing the hospital is looking at doing is they're in the process of completing another community health needs assessment to determine what other needs or what future needs in our community.

So, looking forward to what those reports say.

Yeah, and then getting a windfall in funding that you can do all this stuff yesterday, right? That's always the challenge. Well, Carrie, this is awesome. Congratulations on the award and the fantastic program, but most importantly, the impact that you're having on the patients there.

Thank you.

Western Pennsylvania. That's fantastic. Thanks for joining us.

Thank you.

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