All patients want to stay as healthy as possible and avoid admission to the hospital. For patients with chronic conditions, preventing a hospital stay can be challenging. In 2019, the ACO’s Avoidable Admissions and Readmissions Reduction Workgroup developed and implemented two important interventions to help patients with chronic heart failure, a prevalent condition in Maine, avoid admission or readmission to the hospital.
Heart failure admissions can be reduced with interventions that include intensive care management of patients with heart failure and implementation of a standard post-acute heart failure protocol. Knowing this, the ACO workgroup decided to expand an existing project in partnership with the MaineHealth Cardiovascular Service Line to spread an oral diuretic protocol to skilled nursing facilities. They also took on something new: launching an intensive care management intervention for heart failure patients at risk of admission.
analytics identified patients with hypertension at high risk of hospital admission.The team set to work designing the care management component, which would include chart reviews, home visits and actionable care plans. Patients with heart failure and a greater than 50 percent predicted likelihood of an admission over the upcoming year would be eligible for the intervention. The ACO’s data analysis team harnessed the predictive analytics power of the ACO’s population health management tool and used it to identify 40 patients eligible to participate in the intervention pilot. The ACO’s team of nurse care managers embraced the intervention and quickly launched the pilot.
Meanwhile, the ACO’s clinical education team offered training to skilled nursing facilities across the MaineHealth service area that had not yet implemented the heart failure protocol.
After extensive efforts by both teams, the year came to an end with an impressive level of engagement. The education team traveled to 27 skilled nursing facilities and trained staff there on the protocol. Once the initial care management pilot was successfully completed, care managers extended the intervention to more than 150 additional patients.
These initiatives contributed to a concerted effort across the ACO and the MaineHealth system that resulted in impressive reductions in admissions and readmissions during 2019. We were very pleased to see that the admission rate for ACO beneficiaries fell 10.2 percent and the readmissions rate fell 3.1 percent.