MGMA17: Reducing readmissions may be as simple as a phone call, booking a follow-up appointment

Sacramento, California-based Sutter Physician Services found success in helping to reduce readmissions at its affiliated Sutter Health hospitals by coordinating follow-up appointments and check-in calls with recently discharged patients, but communication and C-suite engagement have been critical to making the effort work.

Gina Bell, MD, Sutter Physician Services’ senior director of clinical operations, said there were efforts to reduce readmissions before the Care Transitions program was implemented, though they were sometimes limited to one of Sutter’s 24 hospitals. The more unified program discussed at the Medical Group Management Association (MGMA) conference in Anaheim, Calif. took a simple approach: Each patient—with the program focusing on patients aged 18 or above—should leave a Sutter hospital with a follow-up appointment with a primary care physician or specialist within seven days and a nurse should place a check-in call to the patient within 48 hours.

Those seemingly simple tasks still needed the engagement of senior managers at the hospital and the outpatient providers, according to Bell, including the CEO. A few problems arose when the process involved physicians outside of Sutter’s integrated network.

“We do appointing for a lot of the ambulatory Sutter physicians, but of course, we don’t do appointing for community physicians,” Bell said. “There had to be conversations … getting permission for us to do a third-party appointing for their patients. Although most allow it, there are still some that still worried enough about no-shows that they only let the patients themselves (make appointments).”

It also took a lot of communication. Bell said there were weekly meetings of the steering committee and work groups involved in the program. Once the program goes live at a hospital, engagement increases with check-in calls every other day or even daily, if necessary, with the frequency of those calls gradually being reduced as a facility gets comfortable with the Care Transitions procedures. Monthly meetings are held to go over quality metrics, with Bell saying she goes over those numbers with case managers at individual Sutter hospitals “once a month or every couple of months.”

So far, the metrics have shown improvement in readmissions rates. Bell said the rate has dropped from 12 percent to 8 percent since the program was implemented four years ago. Analytics being implemented may provide some extra guidance in the near future on how reducing readmissions can affect the hospitals’ bottom line.

“That’s what we’re working on now, what would a 1 percent decrease in your readmit rate mean to your hospital,” Bell said. “The other way we were looking at is what is the cost to the hospital for readmitting a patient and the estimate we got from the system level was something like $12,000 to $14,000.”