Intermountain Health’s Centralized Follow Up Program
In this video, Jenny Simmonds, MSN, BSN, Clinical Communications Center Director, Intermountain Healthcare, shares an overview of their centralized process for following up with patients post-discharge. The program has led to improvements in readmission rates, high-risk patient outcomes, and staff productivity.
Video Transcript
Jenny Simmonds, MSN, BSN, Clinical Communications Center Director, Intermountain Healthcare:
We started this program in 2015. We historically have very low readmission rates and we wanted to keep those readmission rates low and also we were looking at how do we better serve the patients on the back end? How do we get ahead of the game before patients readmit? That was really what the guiding principles of this program were.
We do a lot of value-based contracts and not a lot of VBCs were insisting upon post-discharge programs. But now that this is up and running, we have more and more that are insisting upon having something stood up like this.
We started it off pretty small, with just one program in the inpatient setting. And now, we have expanded to support 25 hospitals and our two standalone emergency departments. We do have a program in our Colorado and Montana area. It’s not integrated with CipherHealth yet, but it is the plan to do that. We were looking at doing that probably this year, and that will put all 33 of our hospitals and our two standalone emergency departments on this program.
Our staffing model is a very centralized team. Intermountain is very big into standardization and quality control. We find with the centralized team, that’s easier for us to do. We can monitor our calls, we can call people and talk to them about their calls, we can play them back for them, have staff listen and be able to see how they are presenting themselves over the phone.
It also helps us standardize the resources that we’re handing out to patients as well. We have a program called “Unite Us” that gives us food and housing resources to make sure that everybody is up to date on what resources that we can hand out for patients as we delve more and more into the SDOH world and try to support those needs of patients.
