Carolinas HealthCare System

Reducing readmissions is a top priority and goal for Carolinas HealthCare System. Our high-quality, integrated healthcare delivery networks have helped us remain better than the national average for readmissions in a number of focus areas, including heart attack, heart failure, pneumonia and chronic obstructive pulmonary disease.

Understanding the complexities of readmissions and the factors that drive them, we continuously put into motion system-wide initiatives and strategies to improve patient health and outcomes. Some of our most recent initiatives focus on community-based home health, skilled nursing facilities, and palliative care and hospice providers to share best practices and reduce readmissions.

Patients with Complex and Advanced Illnesses

Patients with multiple and advanced illnesses are at higher risk for being readmitted to the hospital. Our advanced illness management (AIM) program helps patients with complex health conditions and frequent admissions to hospitals better understand and manage their conditions, as well as reduce the number of times they’re admitted into a hospital. It provides a patient-centered model that cares for the patient’s complex conditions while attempting to link social and behavioral aspects of a patient’s life with the medical resources and access necessary to meet his or her unique needs.

Patient Gwen Frank-Robinson talks about her experience with the AIM program

Six months prior to the start of the AIM program, a group of 25 patients together had 41 visits to the emergency department (ED) and 56 hospitalizations (97 total visits). This total number was down to 33 visits in 6 months – a reduction of 66 percent. We have shown our entire AIM population’s hospital and ED utilizations below. If we combine all utilizations pre-AIM enrollment (241) to post-AIM enrollment (98) we have reduced utilizations by 59 percent. The success of AIM means: reduced ED waits so those seeking appropriate emergency care are seen quickly; reduced hospitalizations and reduced potential infections; decreased healthcare costs; and improved quality of life and patient satisfaction.

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Each time period has a different number of patients because patients are enrolled in AIM at different times. They may not have completed an entire six months, and some patients were discharged when services were no longer needed.

Nursing Homes

Skilled nursing facilities (SNFs) play a big role as partners in the health of our communities. Nursing facilities are the dominant providers of Medicare post-acute care services and can help ensure that patients don’t return to the hospital (patient transfers to the hospital can be costly, disruptive and disorienting for patients). Through the LEAPT contract we have established a SNF collaborative that identifies sustainable solutions to reduce readmissions.

To date, the collaborative has seen an overall reduction in readmissions of almost 14 percent from all nursing homes (33) in the collaborative in just six months. These reductions have allowed our SNFs to stay below the baseline measure (our average readmissions number before the LEAPT contract). Each month we work to reach our goal, or “bold aim,” of reducing readmissions by 25 percent. We achieved this in December 2013 and in April and June 2014.

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Note: The percentages above represent the number of patients readmitted into a hospital within 30 days of being discharged and referred to a skilled nursing facility.

Home Health

Through LEAPT we developed a Home Health collaborative with community partners to drive change and improve outcomes. The collaborative put into place 5 interventions to reduce readmissions for patients with high or very high risk for readmission.

Through the Home Health collaborative, we were able to reduce readmissions among these patients by more than 24 percent in just six months (surpassing our bold aim).

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Note: The percentages above represent the number of patients readmitted into a hospital within 30 days of being discharged and referred to Home Health agencies for care.

Hospice and Palliative Care

Patients who are chronically or terminally ill do not always receive the type of specialized care they might need, and this is especially true for minority patients. To increase use of hospice and palliative care among eligible patients, we are partnering with a number of groups, including the System’s Diversity & Inclusion Department, Multi-Cultural Physician Resource Group, Palliative Care and Hospice Network, and Hospice and Palliative Care Charlotte Region.

We are focused on providing these patients with multiple community resources and on creating a unified method to encourage advance care planning and accurately document this in the electronic medical record. As a result, more and more patients are learning about and using these services when deemed clinically necessary. The rate of referrals for these services in a nine-month period increased almost 20 percent for non-white patients and 19 percent for African American patients.

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