Hospital readmission is a common challenge for health systems in the U.S. However, many are now looking to digital tools to help curb the rate of high-admission patients. 

This year Atrium Healthcare won a HIMSS Davies Award of Excellence for its digitally enabled approach to addressing hospital readmittance. 

“With 50 hospitals and a broad footprint, being able to identify individuals who are at risk and intervene, from a readmission standpoint, is not only a patient-care imperative, it has huge capital and financial implications,” Ruth Krystopolski, senior vice president of population health at Atrium Health, said during the Davies acceptance presentation, which was part of HIMSS20 Digital. 

The team began investing in creating visibility across the population by working with Cerner to use the HealtheIntent platform. 

Krystopolski said that the team started off small identifying potential patients that were frequently in the hospital. They started with a patient that she referred to as “Joe,” who had within the last few years racked up 1,500 hospital visit, and within a six-month time frame already had 120 visits. Joe had a number of conditions, including PTSD, anxiety, hypochondria and major depressive disorder. 

Using data, the team looked at this case and was able to line up and address a number of factors in care. These factors included care team meetings, obtaining housing, daily behavioral health therapy, an assigned primary care doctor, daily community paramedicine and access to a cell phone, food stamps and Medicaid. This led to a significant drop in his hospital visit rate. In fact, since June 2018, this patient has only been to the emergency department 39 times. 

Atrium then used this method to examine other frequent readmission cases, enrolling an additional 84 patients in this holistic approach. This led to an over $1 million decrease in hospital spending, and a 55% deduction in hospital use by these patients. 

“None of this would have been possible without the aggregation of data and interventions at the HealtheIntent platform level, and then serving this information up into workflows of our care managers both on the floor and in the ED, as well as allowing us to measure and monitor progress across the broader system.”

These efforts continued to expand to look at other patient populations. In 2018 Atrium worked on a project on a system-wide level to identify the highest emergency department users. The organization took a three-pronged approach: creating visibility within the data to pinpoint the frequent users, defining a plan for each patient to connect them to appropriate care, and looking at the underlying social determinants of health that impact patients. 

“For the patient cohort we had for 2018, that had more than 20 visits, we reduced their actual visits across the year by 40% and reduced the charges for this patient population by 39%, which scaled up across the Atrium footprint is about $16.6 million in charges reduced.”

So far, the team has seen similar results in this expanded patient population, and it looks to continue the process.