In the summer of 2017, as part of a first-of-its-kind new contract with Independence Blue Cross (IBC) — the largest commercial insurer in our region — the University of Pennsylvania Health System made a promise: that we would work around the clock to find new ways to make sure our patients didn’t need to return to the hospital after being discharged. The stakes were high — when we were unsuccessful, IBC would not pay us for those readmissions.
A year later, data shows unprecedented success. Since the program began, we have cut readmissions by more than 30 percent among patients insured by IBC. It’s the largest readmission reduction in our organization’s history.
This initiative was a bold component of our entry into IBC’s new Facilitated Health Networks model, which is designed to engage both the insurer and health care providers in the development of new initiatives to improve care quality and cut costs for patients insured by IBC. We’re a destination for patients with some of the toughest conditions, including those who need leading-edge organ transplants, cardiac and neurosurgeries, suffer from cancers that haven’t relented in the face of an arsenal of standard therapies, or have rare diseases that defy answers at many of the nation’s other hospitals. Many patients are juggling multiple complex conditions — diabetes and heart disease, for instance — which put them at even greater risk for complications.
A carefully orchestrated process must come together each time a patient is discharged from the hospital. Though some patients will need to come back no matter what, like those undergoing scheduled inpatient chemotherapies or phased surgeries, a single missing piece — or stroke of bad luck — along the way can mean the difference between recovering at home and a return trip to one of our hospitals. There are many reasons why patients may need to be readmitted. Some are clinical in nature, such as infection or a flare-up of a chronic condition, while others may be due to socioeconomic and other factors, such as transportation issues that make it difficult to keep follow-up outpatient visits.
Over the years, we’ve developed numerous efforts aimed at cutting readmissions, but the problem remains stubborn: Across the nation, hospitals’ typical interventions only cut readmissions by an average of 1 percent annually. So what made the difference this time? It all starts with data, leveraging our systemwide electronic health records platform to identify patients at high risk of readmission, which includes many with cancer, heart disease, gastrointestinal conditions, and sepsis. Newly developed dashboards within PennChart provided clinicians across our many care settings, including emergency departments, outpatient clinics, home care, and other care settings, with access to real-time insights on each high-risk patient. The platform guides clinicians to take proactive steps to reduce common post-discharge hurdles. Now, patients who are found to be at high risk of readmission receive a call from a scheduler who assists in setting up all their follow-up outpatient appointments — typically combining them on the same day — even before they’re discharged from the hospital.
Patients now also leave the hospital with all their prescriptions in hand to avoid any delays in beginning new drug regimens. Studies show that patients often struggle to retain and follow through with the information they receive when they’re discharged from the hospital, so we’ve implemented new processes to ensure that patients receive home care. This represents another opportunity to provide important medication and disease management teaching. Technology has also played a role, with remote monitoring for high-risk patients — a strategy we previously developed to identify complications among heart failure patients and new mothers — helping to identify and treat any problems quickly.
We also analyzed data to identify patterns that we can address without readmission. For example, we found that many cancer patients were readmitted through the emergency room. In response, the Abramson Cancer Center launched an Oncology Evaluation Unit where patients can be seen as outpatients and effectively treated for common issues like dehydration.
This effort took expertise and dedication from all sectors of our system, including physicians, nurses, pharmacists, data scientists, social workers, and finance professionals. As we build upon our success, the importance of this collaboration will only continue to grow. It’s teamwork that cuts costs and is paving the way to bending the curve of increasing health care costs across the nation. Most importantly, it’s teamwork that keeps our patients healthier and in their own homes.