When Amy Smith, assistant vice president for the Care Transitions Group, and Josette Armendariz, assistant chief nursing officer and director for Patient Care at UTMB, sit down with the UTMB CARE (Controlling Avoidable Readmissions Effectively) collaborative group each month, the mission of the meeting is simple—discuss and explore ways UTMB can continue to reduce the number of 30-day all-cause hospital readmissions.
Defined as patients who return to the hospital within 30 days of their most recent discharge, 30-day readmissions at UTMB have been on the decline recently—boasting a 14.5 percent drop over the last two years. This trend is indicative of the shift taking place in how care is approached and delivered not just at UTMB, but at health care institutions across the industry. at UTMB have been on the decline recently—boasting a 14.5 percent drop over the last two years. This trend is indicative of the shift taking place in how care is approached and delivered not just at UTMB, but at health care institutions across the industry.
“The focus is on keeping people well and keeping people out of the hospital,” said Smith.
Complementing and enabling this evolving approach to health care is UTMB Discover— an enterprise data warehouse and analytical toolkit that, through the use of various applications within it, aggregates real-time, accurate data generated by UTMB’s mission areas.
Launched in December 2016, the data-mining tool presents a wide variety of information in an easy-to-understand way that helps data analysts like Ruth Russell with the Care Management Administration team more quickly develop reports and spot trends or anomalies occurring within UTMB’s operations.
“Before UTMB Discover, data analysts like me would run monthly reports and send those out for care managers, clinicians and others to retroactively review and assess their operations,” said Russell, a senior business systems analyst. “But now, thanks to this system, it’s all automatic and live data anyone with access can see at any time. So, it’s become a much more immediate and proactive process, and we are now free to focus our energy on looking for trends, opportunities or anomalies that may need special attention.”
The reports and trends members of the CARE collaborative group are most interested in are generated by the Readmissions Explorer, an application within UTMB Discover built to specifically address and examine factors that may bring a patient back to the hospital in that 30-day window of being discharged. Comprising UTMB nurses, physicians, pharmacists, care managers, social workers and others, the multidisciplinary CARE team uses these custom findings to explore potential solutions and make quicker, better-informed decisions when it comes to the care they deliver each day.
Thanks to the Readmissions Explorer findings and these regular discussions, Smith—who’s been on board with UTMB for just over a year now—and the Care Management team have already implemented some operational changes, including offering video visits as an option to patients who have questions or concerns following their discharge. The remote visit saves the patient time and money by eliminating the need for a physical trip to the hospital. She and her team have also worked to streamline and centralize the process for patient follow-up phone calls.
“Previously, there were a lot of different areas making these calls for the same patient,” said Smith. “To keep the process consistent and reduce confusion, we’ve streamlined that so it now is exclusively under the care management umbrella.”
It’s critical that post-discharge conversations are given special attention, because they give care managers a chance to reiterate any special instructions patients need for their recovery and also gives individuals a chance to ask any questions they may have. Plus, by centralizing the process, there’s less chance a patient will receive conflicting directions or unclear messages, which ultimately leads to an overall better care experience while saving time and money.
These are just a few examples of the work and initiatives resulting from the increased availability of shared data, made possible by UTMB Discover and the Readmissions Explorer Application. In addition to directly improving the patient experience and furthering UTMB’s efforts to provide Best Care, the reduction in readmissions work is also garnering attention at the UT System level, as health institutions are beginning to compare performance in some of these areas.
Dustin Thomas, vice president for UTMB Decision Support, has been integrally involved with the UTMB Discover initiative since joining the university in 2016. He is pleased with the results the tools have delivered thus far, noting that the recent reduction in UTMB’s readmissions rate alone has saved the organization nearly $2 million in related costs.
“It really has been a two-year journey and we’re at a good spot right now where we’ve seen some good returns,” says Thomas. “UTMB Discover makes it possible to see that our institution is making statistically significant changes in the way we are providing care.”
Just two years into UTMB’s transformation into a more data-driven institution, there’s no telling where this journey may lead, but one thing’s for sure: providing the best care possible to every patient, every time will remain at the forefront of the organization’s mission.
“It all comes back to better patient care,” said Smith. “That’s what it all boils down to.”