Innovation Spotlight - Triple Aim: New York Hospitals Are Improving Health, Enhancing Quality, and Reducing Costs.

Arnot Ogden Medical Center is Reducing Readmissions

Arnot Ogden Medical Center is reducing hospital readmissions with their Medicaid Accelerated eXchange (MAX) Program. Addressing patients with four or more inpatient admissions within a twelve-month period, this program helps facilitate system integration by breaking down silos and bringing together multi-disciplinary providers to care for mutual patients.

When a patient with four or more admissions is in the ER, a real-time alert activates and the Action Team of emergency department and outpatient case managers, community-based organizations, and physicians is mobilized. Patients receive a palliative care screen and psychosocial assessment, and any identified needs or services are addressed and communicated. Bedside huddles serve to include patients in conversations regarding their care, and multidisciplinary care conferences are held to develop care plans that are accessible when patients return to the ER. An Analytic Dashboard evaluates trends, length of stay, readmissions, and 90-day pre- and post-utilization.

As a result, hospital utilization has decreased by 60% for patients admitted in March 2017 with the above interventions.

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