The New Helping Hand: Preventing HIV Readmissions with Technology

HIV can be a terrifying and isolating disease in the modern age of medicine despite major advances in research. Patients that are HIV positive still suffer from depression and stigma, as the disease is one without a cure. The virus can easily mutate, and patient populations struggle with medication compliance. In addition, HIV-positive patients’ condition greatly weakens their immune systems, leaving them susceptible to other illnesses. Readmissions for this patient population are costly, frequent, and disproportionate.

Despite these challenges, a 360-bed Academic Medical Center in San Diego took on the seemingly behemoth task of reducing readmissions within the HIV-infected population. According to a 2015 study, the average readmission rate in the United States for HIV-positive patients is between 19-25%. Although the San Diego hospital’s HIV readmission rate was already significantly lower than the national average, at 12.4%, hospital leaders felt this was something they could further improve.

Meeting the Follow-up Needs of HIV Patients

In order to maximize the potential for success, the medical center partnered with CipherHealth to launch CipherOutreach, the industry-leading patient outreach solution. The hospital implemented CipherOutreach to automatically call all HIV patients post-discharge to check in on their conditions, identify any questions or concerns, and gather feedback on their hospital stays.

If a patient reports a question or potential issue, an alert is triggered to a designated clinician, who will manually call the patient to resolve the concern. This process ensures that patient issues are resolved promptly and effectively, helping to prevent avoidable readmissions. After nine months of using the follow-up platform, the readmission rate for HIV-positive patients discharged dropped from around 12.4% to a readmission rate of 5%.

“These results illustrate the importance of early intervention in preventing readmissions within high-risk patient groups,” said Alex Hejnosz, CipherHealth co-founder. True to this statement, the hospital has found that over 65% of HIV patients called with CipherOutreach engage with the call. Of those who engage with a call, 42% require manual intervention from a clinician. This high issue rate shows the importance of reaching out to this high-risk population.

With CipherOutreach reports, the hospital has in-depth insight into how long it takes for staff members to reach out to patients indicating an issue. As a result, clinicians were able to understand the impact of rapid issue resolution and decrease their median intervention time to 20 minutes.

Hospital-Wide Success with Effective Follow Up

Similar success with the CipherOutreach program has been seen for Orthopedic and Cardiovascular patients. Readmission rates for these patients have respectively dropped by 74% and 67% since the launch of CipherOutreach at the hospital. Aside from being able to efficiently triage patient issues, CipherOutreach provides hospital leaders with a large volume of in-depth data, which helps inform and drive improvements to patient care.

Through the data gathered on the automated calls, the organization was able to pinpoint the most common reasons patients required manual callback. They found that the most common reasons for callback were non-clinical: transportation help, scheduling a primary care physician appointment, and scheduling a follow-up appointment. This information has helped the hospital drive further improvements to discharge planning by working to ensure that all patients can easily travel home and have future appointments scheduled.

Conclusion
Overall, technology can help to mitigate the challenges presented by a high-risk patient’s care journey. Specifically with HIV-positive patients, care solutions like CipherOutreach offer yet another touchpoint for patients to express concern or misunderstanding, thereby improving outcomes and decreasing readmissions.

As CipherHealth’s Chief Nursing Officer, Lisa Romano, MSN, RN brings more than 25 years of experience in clinical practice, healthcare IT strategy, and healthcare operations to her current role. Prior to previous CNO roles, Lisa spent 19 years as a nurse and hospital administrator at Lehigh Valley Hospital and Health Network in Allentown, PA, where she was responsible for all patient flow and transfer center operations as well as numerous quality and patient satisfaction initiatives. Lisa is passionate about improving the health of patients across the healthcare continuum.