Leveraging CipherOutreach to Improve Clinical Outcomes Across the Continuum

Improve Clinical Outcomes

CipherHealth’s 2019 Partners In Excellence User Conference brought together CipherHealth users from across the country to network, have fun, learn and share best practices around patient engagement strategies. During the panel session, “Leveraging CipherOutreach to Improve Clinical Outcomes Across the Continuum,” leaders from four health systems shared how they utilize proactive outreach to make patient care better at each of their organizations.

Sharing Strategies Across the Care Continuum
The panelists included Ben Becker DNP, RN, NEA-BC, Director of Enterprise Care Management at Intermountain Healthcare, Charnicia Huggins PharmaD, MS, AE-C, BCABP, Clinical Pharmacist at BronxCare Health System, Namgyal Kyulo MBBS, DrPh, Director of Healthcare Experience Analytics at UCLA Health System, and Katherine Major MSN, RN, CHPN, Director of Penn Home Care and Hospice Service at the University of Pennsylvania Health System.

The panelists represented organizations that spanned the country and care continuum. Using data and personal experiences, they discussed how CipherOutreach can be customized to meet the unique needs of various departments and patient populations.

Meeting the Needs of Specific Patient Populations
Huggins shared how BronxCare initially set out to improve the follow-up process for patients discharged on home IV antibiotics. They wanted to overcome the lack of readily identifiable physicians, ER visits due to elevated serum drug concentrations, and other potential modifiable circumstances.

By partnering with CipherHealth in 2016, patients discharged to home on IV antibiotics now receive five automated calls between 2 and 40 days post-discharge. The questions on the calls regard patient satisfaction, discharge instructions, follow-up appointments, contact by a visiting nurse, blood draws, and medications. If a patient responds negatively to any of the questions alerts are immediately relayed to care transitions pharmacists or care transitions nurses.

Major went on to explain how the Palliative Care program at the University of Pennsylvania has grown significantly in a three year period and even though their staff has grown to help meet those needs, CipherOutreach has been able to help make the most efficient use of those resources. For Major and her team, supporting Palliative Care patients also means supporting their loved ones through the use of outreach.

The Importance of Setting Programs Up for Success
As Major explained, for her team, the success of the program was dependant on the people behind it. By having great people, a clear mission and vision, and a single-minded purpose, they were able to achieve both experience improvements and reduce adverse events.

As a way to foster the ongoing improvements of the Intermountain Health Answers Program, Becker recommends adding a bit of healthy and positive competition to the process. This has led to better outcomes for the patient and bit more engagement from the staff who are helping to address patient concerns.

For BronxCare, they needed to ensure that patients would be adequately educated about the automated calls. Patients that are enrolled in the outreach program receive an email notification to ensure they are ready for the automated calls.

Improved Outcomes Across the Care Continuum
Kyulo from UCLA Health explained that with the use of CipherOutreach for post-discharge follow up, he and his team were looking to improve HCAHPS scores, as well as their readmission rates. In analyzing HCAHPS data, the team saw that patients who engaged with the program saw a significant improvement in how they responded to questions, especially those related to nurse and doctor communication, staff responsiveness, and care transitions. Additionally, patients who engaged with the calls were nearly 35% less likely to experience a 30-day readmission.

In the case of BronxCare, Huggins shared how the team was able to identify the most common issues patients experienced post-discharge, as well as the top indicators of readmissions. Patients who engaged with the call had a significantly lower readmission rate in comparison to those who did not participate.

At the individual level, Becker highlighted a story of a patient who had called four different pharmacies in the hopes of obtaining her prescription. After indicating that she needed help with medications on one of her outreach calls, the pharmacy was alerted and able to help the patient. This process created a better experience for the patient and ensured that she was able to follow her care plan.

Sharing Lessons Across the CipherHealth Community
As the panelists spoke to how they have achieved success, attendees were able to ask questions and bring back takeaways to their own organizations. With the breadth of options provided by CipherOutreach, each panelist offered a unique perspective as to how they are achieving positive outcomes for their patient populations.


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