Hypothesized Pathways and Illustrative Quotes for Activities (Within Strategies) to Reduce Acute Hospitalizations at AHR High Performers
| Activities (Within Strategies) and Hypothesized Pathways | Illustrative Quotes |
|---|---|
| Improve access to primary care | |
| Same-day visits: Increasing same-day appointment slots allows more patients to see a clinician at the practice quickly for urgent needs or concerns, and can help avoid primary care–treatable ED visits. Same-day visits also decrease the chance that an ED visit might result in admission, and help address clinical issues before they become more severe. | “More frequent and appropriate use of the acute [primary] care system prevents hospitalizations, and that’s what we are doing with same-day availability. Get ‘em in and get them assessed before they seek ED care or put off care that could result in an acute admission.” – Care manager “Just having that access and the spots on our providers’ schedules for acute visits helps. Before patients said it was easier to go to the emergency room. Now, they’re able to get in right away to see somebody.” – Care manager |
| Direct access by telephone: Sharing direct telephone numbers to care managers and encouraging patients to call (and having patients know that someone who knows them will answer or respond quickly) can increase patients’ likelihood of calling the practice when they have a question or concern rather than turning to the ED. It also promotes earlier intervention to prevent exacerbations that might lead to an ED visit or hospital stay. | “We had started an after-hours on-call number we gave to the patients, put on our cards also, that gave them access to a nurse care manager after hours and on the weekends. And I believe with us being able to triage those patients and take care of their needs, that has reduced them going to the ER and the hospital for hospital stays.” – Registered nurse “We have strict standards in terms of coverage telephone after hours. We try to make sure that they [patients] are told to come to the office the next day instead of the emergency room, if appropriate.” – Registered nurse |
| Urgent care sites (system run): Establishing urgent care access with EHR linkages to the primary care practices provides as alternative to the ED for patients to receive treatment for an acute episode when the practice is closed and may prevent ED visits and lower the chance of hospital admission. | “… in our community, we didn’t have an urgent care center before, so patients used our emergency room at our local hospital instead. By adding the urgent care here, we can keep people out of the hospital whether it’s in the emergency department or being admitted.” – PCP “[These same-day care centers are] very different from other urgent cares in the community. These are our own people and it’s really very much a primary care–driven approach… when you had a patient that went to these centers, it was really more like they saw one of your partners in the office. The centers are open until 8 at night and for 4 hours on Saturday and Sunday. I think that was a pretty major driver [of reduced AHR].” – System lead |
| Expand care management | |
| Follow-up after hospitalization/ED visit: Connecting with patients immediately after discharge from the hospital or ED provides patients with information, support, and linkages to care that can prevent future hospitalizations. For example, practices could identify and address issues with medications, transportation, and DME services needed after discharge and schedule timely follow-up with primary care. Transitions of care are also an opportunity to funnel patients to longitudinal care management services. | “There are so many different things that bring a person back to the hospital… couldn’t afford the copay, didn’t have a ride to the pharmacy, and so on. We wanted to keep [our follow-up calls] very open-ended, and a robot can’t do that. I’m all for IT, but you really need a human who is listening to what you’re going through and so that was the core of our transitional care; we really wanted that personal touch.” – Program manager “An integrated Transition of Care Management program was the biggest lever on the AHR, not just a person. The care manager was vital, but she would not have been successful without the other things that she fit into and benefited from. So not just a person, it’s a process and a program.” – System lead |
| Long-term care management: Identifying and engaging patients with complex or comorbid conditions in relationship-based longitudinal care management can prevent or lessen the severity of exacerbations that might otherwise require hospitalization. | “[It’s been] important to have a team that tackled high-risk patients and hospitalizations together as a team. Divvied up the work, made sure they took care of all the details.” – PCP |
| Specialized programs: Offering clinical programs designed for subgroups of patients at high risk for hospitalization can allow practices to identify emerging issues early and focus services where they may have the largest impact on hospitalization. | “We saw our COPD admission rate and readmission rate drop dramatically from [the specialized albuterol program]. We identified patients that may be experiencing COPD exacerbations by tracking their albuterol refill rate. Their refill rate triggered us to reach to those patients.” – PCP “Like our A1c [values]—we watch our diabetic patients. We watch our diabetic patients a lot closer than we used to. I think it helps us catch things early. It helps them realize, ‘Oh my gosh, my A1c is super high,’ and it brings it to their attention to improve on those so that they don’t end up in the hospital.” – Care manager |
| Increase comprehensiveness of care | |
| Broader services at practice: Viewing the needs of the whole person rather than just isolated problems might lead to fewer hospitalizations. Expanding the ability to provide services such as behavioral health, pharmacy, and social service support can prevent exacerbations of chronic conditions that might lead to hospitalization and reduce the likelihood of presentation for new conditions requiring hospitalization. | “I think that it [CPC+] just brought to the forefront that, you know, trying to take care of the whole patient with the education, working with the team on getting the full picture of what this patient needs, and keeping the patient involved in what they need to do to stay out of the hospital. I think that just seeing all of that together and not just piecing things together and just taking care of 1 problem when they come in, but doing the whole person.” – Care manager “We’ve got this team of physicians, of pharmacists, of care coordination, and also of integrated behavioral health. All these could potentially work together to make certain a person needs to go to the hospital, vs being treated at the practice, and we can make those decisions as a team.” – PCP |
| Broader and deeper care provided by PCP: Transitioning tasks to others frees up PCPs so they can spend more time on care of patients with complex needs—and thus better understand patients’ circumstances and conditions, ensure appropriate diagnosis and treatment plans, and build trust. | “I felt freed up to do those things that I really wanted to do, as a doctor, to actually talk to my patients and have them take care of their health. Shifting the nonprovider work to nonproviders allowed us that extra time to do these provider things we really wanted to do, that made us feel good about our work.” – PCP “We have longitudinal relationships with patients, which gives us more time with patients to learn about social determinants that affect their health, to communicate to patients how to better care for themselves, and the ability to notice changes to the patients’ health over time and intervene early.” – PCP |
A1c = glycated hemoglobin; AHR = acute hospitalization rate; COPD = chronic obstructive pulmonary disease; CPC+ = Comprehensive Primary Care Plus; DME = durable medical equipment; ED = emergency department; EHR = electronic health record; IT = information technology; PCP = primary care practitioner.