May 27, 2020

Reduce Readmission Rates with Follow Up Appointments

Matt Perron

Reducing hospital readmission rates has been a longstanding goal for most health systems and the Hospital Readmissions Reduction Program (HRRP) formalized this goal by creating incentives (and penalties) for reducing readmissions for certain diagnosis. Now with COVID-19, reducing readmissions and therefore freeing up hospital capacity has never been more important. According to a recent study, patients who received follow up care with a PCP had lower 30 day and 90 day readmission rates.  

What can your organization do to achieve this?   

The Wilshire Group recently partnered with Harris Health in Houston, TX to implement a process to ensure that inpatients received a PCP follow up appointment before being discharged. We wanted to highlight some of the key aspects that Harris Health implemented as they are more applicable now than ever. Below are a few of the features of this program:  

  • Communication Between Care Team and Schedulers – The first step in the process was finalizing an effective way for the Care Team of the patient to notify the schedulers that a patient required a follow up appointment with their PCP. Like many health systems, Harris Health uses a centralized scheduling department that is in an entirely different building than their hospitals. They utilized workqueues in Epic to route these follow up requests in real time to the right people so they could be acted on immediately.
  • Dedicated Schedulers – Timelines in scheduling these appointments is critical and with a goal of the patient having an appointment scheduled before discharge, a small group of schedulers was necessary. These schedulers monitored the workqueue throughout the day and would immediately begin scheduling a request as soon as it was sent. As someone that was monitoring the workqueue to make sure it was functioning appropriately, it was extremely impressive to see how quickly the scheduler were able create these appointments. Even though these schedulers were also still doing some of their normal scheduling responsibilities, the small team allowed for clearer ownership and accountability.
  • Communication to the Patient – When an appointment was scheduled, that information would automatically show up on the after-visit summary (AVS) for the patient. The centralized scheduling department collaborated with nursing to create specific verbiage and a specific section of the AVS so that nursing could communicate the appointment details. In scenarios were an appointment time wasn’t able to be found, there was logic to display next steps to the patient, so they knew who to follow up with or who to expect a phone call from. 
  • Reporting – We needed a way to track the patients that were being scheduled. As part of the pilot, we created reports that showed both scheduled and unscheduled appointments. In the long term, it will be valuable to track these patients as part of current readmission reporting to see what impact scheduling follow up appointments has. 

Going forward, this framework for reducing readmission rates can be used to schedule both in person and telehealth visits, which are more prevalent than ever with COVID-19. For patients that were admitted with COVID-19 or are in a highrisk group, the dedicated schedulers can identify them and better coordinate their follow up careThe existing framework could also provide COVID-19 specific next steps to the patient upon discharge so they know how the follow up care will be handled.   

The initial pilot of the program was a huge success and it was nominated for an innovation award at Harris Health. It was a personal honor to be able to partner with Harris Health on this initiative and I look forward to bringing this to future health systems we work with. If you have questions about some of the specifics of this initiative, please contact  Matt Perron  at The Wilshire Group –  Whether or not you are a current client, we would love to partner with you to implement this process at your health system.

Matt Perron

Manager, Patient Access

Work with me