Indiana University Health’s Post-Discharge Follow Up Process
In this video, Adria Grillo-Peck, MS, RN, CMC, Vice President Integrated Care Management, Indiana University Health, shares the process for engaging patient’s post discharge. IU Health’s centralized approach ensures timely follow up that drives better outcomes and experiences for their community.
Video Transcript
Adria Grillo-Peck, MS, RN, CMC, Vice President Integrated Care Management, Indiana University Health:
Our program was actually implemented in 2016. I joined IU Health in 2014 and I was working with the Chief Nursing Officer of our academic health center and she had two dedicated RNs that were doing this work. They were tracking some of their outcomes, but their reach rates were anywhere between 5 percent and 85 percent. And 85 percent was actually on the BMT unit. Those patients typically stay longer, you develop a relationship with them.
We knew that we had a lot of work to do. That’s kind of how we started—she gave me those 2 FTEs, and we partnered with CipherHealth, and it’s been a journey ever since. We did start with our academic health centers, which is 2 of our hospitals—Methodist and University. And then we expanded from there to other hospitals, as well as we implemented in our different facilities that have emergency departments.
Our staffing model, we have a centralized team of three transitional case managers. For us, the centralized model has worked very well because we have the infrastructure to cover if someone’s on PTO or later in the hours. One of our individuals actually works on Sundays, which is great for our cadence calls, and then we’re able to catch those patients on the weekend.
We have one transitional case manager that is specifically devoted to Riley, which is our children’s hospital. The workload of that patient population is very great. In Indiana, about 49 percent of these calls actually require an interpreter. The calls just take a little bit longer.
Our objectives and key performance indicators, readmissions, patient engagement and then again, looking at what is our ROI.
We have stood up a readmission steering committee. And it’s a system-wide steering committee, but we will be very focused on patient outreach as one of our objectives. Our philosophy is more system-led, so this is the initiative but locally or regionally operationalized. What we are in the process of doing now is developing some standards of what the minimal requirement is. We’re still defining those. So, much like the reach rate being 90 percent and the turnaround time be an hour.
