Intermountain Health: Improving Clinical Outcomes and Reducing Readmissions

Intermountain Health: Improving Clinical Outcomes and Reducing Readmissions

Intermountain Healthcare – the largest nonprofit health system in the Intermountain West

• Mission: Helping people live the healthiest lives possible
• Vision: Be a model health system by providing extraordinary care and superior service at an affordable cost

Post-Discharge Calls: 2014, before the implementation of CipherOutreach

• Decentralized model, dependent on each unit managing their own follow up
• Little or no coordination between those calls and outreach at the clinic level
• No tracking or documentation of calls
• No resources to help the patient in case of a need for service recovery
• No dedicated time to help nurses focus on making meaningful calls

Post-Discharge Calls: 2015, during the implementation of CipherOutreach

• Shift to making centralized calls using CipherOutreach, leading to improved efficiency

• Shift to a centralized approach also allowed focus time to make these calls and take next steps to address concerns

• Free up bedside staff for patient care

• The primary goal: reduce readmission rates and ED bounce back rates across the system

• Secondary goal: increase patient satisfaction

• Creation of the Health Answers team

• Aim:

• A service aimed at providing timely, free, and accurate health information and follow up to ensure seamless transitions - ### Staff:

• Staff members are nurses with more than 5 years of experience from varied cultural backgrounds. Training includes phone skills, boundaries, and available resources

Goals of the CipherOutreach implementation and Centralized Post-Discharge Calls

• Seamless transitions for patients, leading to reduced readmissions
• Standardization of calls for all Intermountain Healthcare patients, regardless of how busy their unit of discharge might be
• Post-discharge clinical insight, which helps to highlight problems at the unit or hospital level
• Standardized documentation and issue resolution

Patient Education is Key

• Patient education prior to discharge
• Automated call
• 24-48 hours
• Nurse will call back based on responses

Post-Discharge Follow-Up Focus

• Clinical vs. Patient Satisfaction
• Post-discharge follow-up call focused on clinical issues
• Understanding of discharge instructions
• Obtaining prescriptions
• Questions about medications
• Follow up appointments
• Barriers to follow up
• Clinical specific questions
• Not a patient satisfaction call

CipherHealth Voice (now CipherOutreach) Automated Calls/Texts

• 4 attempts to reach patients over 1-2 days
• Voicemail messages left it patient does not answer
• Return calls trigger human follow up automatically
• Negative responses trigger a live call from an Intermountain Health Answers nurse
• Documentation is kept in the EMR (bidirectional interface)

Health Answers Staff

• Experienced nurses > 5 years experience
• Varied clinical backgrounds
• Orientation and training include:
• Phone skills
• Boundaries
• Resources
• Clinical resources

Health Answers Nurse Follow-up

• Timely follow up on issues (goal of less than 30 minutes per issue)
• Ensures patients make seamless transition to primary care provider, reducing leakage
• Help find solutions to any barriers
• Escalate care as needed
• Documentation in the EMR, enabling identification of common issues or trends

Readmission Rates Improvements

• 4.9% of patients who received a phone call we readmitted within 30 days. We can see that patients who engage with outreach programs have lower readmission rates than patients who do not engage with the programs.
• The average difference in readmission rates between engaged and unengaged patients is 2.6 percentage points

## Key Takeaways

• Voice, now CipherOutreach, helps identify patients requiring intervention to efficiently focus nursing time
• Identification and resolution of patient concerns/issues reduces readmissions
• Patient engagement post-discharge calls impacted by upstream education