Supportive Medicine Reducing Readmissions

The Supportive Medicine program deploys an interdisciplinary team composed of clinical providers, nursing, and psychosocial support to bolster care coordination, resources, and treatment plans for patients and families. The goals of care discussions and effective communication skills of the team produced decreased levels of readmissions across the system.

Discharge disposition data will be shared to further demonstrate the effectiveness of Supportive Medicine interventions for seriously ill patients in the Houston area.

I. Background:

The Supportive Medicine program for Memorial Hermann Physician Network utilized programmatic process improvement to realize readmission gains from palliative care in the acute setting. A detailed process mapping and role definition initiative helped drive efficiency and quality during goals of care discussions and medical services.

II. Aim Statement:

Improve the efficacy of palliative care for patients during their transitions of care and discharge.

III. Methods:

Leveraged process improvement/Lean principles to capture readmission gains - process mapped to identify value and non-value added activity within the program. Noticed many instances where the interdisciplinary team could be deployed to give time back to the program. The time saved was then given back to patient care. Patients were able to spend more time conversing with the appropriate team member.

Took the top 6 APR DRGs for the Supportive Medicine program and compared these to the system control group (same 6 DRGs). These DRGs included the following:

  • Pulmonary edema - respiratory failure
  • Chronic obstructive pulmonary disease
  • Heart failure
  • Acute kidney injury
  • Infectious parasitic diseases, including HIV w/ OR procedure
  • Septicemia disseminated infections
  • The DRGs comprise nearly 90% of the consult volumes the program sees in a fiscal year.

We also measured the discharge dispositions for the program to drill further into the analytics. Supportive Medicine was able to leverage goals of care discussions to guide discharges for the most severe patients into their appropriate post acute care settings.

IV. Results:

Readmission scores for the palliative were nearly half (9% vs 18%) of the system averages. The program rarely (less than 5%) sent patients in this higher severity bracket, home with no accompanying services.

V. Conclusions and Implications:

The importance of Supportive Medicine in the chronically ill disease process is critical to effectively educating patients on their conditions, outlining treatment plans, and planning quality of life.

Author

Michael J DSouza, JD
Manager of Supportive Medicine
Memorial Hermann Physician Network
909 Frostwood Dr, Suite 1.408
Houston, TX, 77024
(713) 338-4659