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
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
