Jamaica Hospital Medical Center reduced readmissions among frequent inpatients with a model it developed through the Medicaid Accelerated eXchange (MAX) program. The model’s focus is on patients with four or more inpatient hospitalizations within a 12-month period.
To easily identify a MAX patient, a Best Practice Advisory alert in the form of a bright red “M” appears in the patient’s medical record upon emergency department registration. Real-time notifications also appear to clinical and administrative leadership, including a root cause analysis team, which holds a teleconference within 24 hours of the patient’s admission to discuss underlying medical and social determinants. Medical chairpersons then create a comprehensive care plan for each MAX patient. Dedicated patient care facilitators ensure medical, diet, and primary care compliance by calling and making home visits for 180 days.
As a result of these combined efforts, the MAX patient readmission rate has decreased 51% since the program’s start, and a 90-day pre- vs. post-utilization analysis shows a 70% reduction in admissions.