New collaborative care program reduces HF readmission rates

March 11, 2022

5 minute read


Source/Disclosures


Source: Healio Interviews


Disclosures: Gattis is CEO and co-founder of LeadingReach. Magoon does not report any relevant financial information.


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A chronic disease management pilot program designed to digitally connect health care providers and community agencies has reduced readmission rates for HF and improved communication among care team members, according to a case study.

The South Texas Physician Alliance (STPA), an independent physician association serving the lower Rio Grande Valley, worked with healthcare communications company LeadingReach to digitally coordinate care for its Heart Failure Reduction Program . The 30-day program is initiated when the hospital sends a collaborative referral for a patient with heart failure. Care team members use a digital platform to confirm appointments, communicate issues through a team chat function, and share documents.

The program is designed to improve the general well-being of the patient; however, STPA also observed an overall reduction in HF readmission rates as well as better coordination of care between agencies, according to Sheila Magoon, MD, CEO of STPA.

Sheila Magon

Curtis Gattis

Healio spoke with Magoon and Curtis Gattis, CEO and co-founder of LeadingReach, on the importance of collaborative care in IC, anticipating patient challenges, and plans to expand the program beyond IC.

Helio: Why was this type of program necessary?specifically for HF?

Magon: We have had readmission issues and high admission rates in our area for many years. This question has always been on our radar and we have approached it from different angles. When we looked at Medicare data for heart failure specifically, our readmission rates were between 22% and 23% in our region. It’s something we have to figure out how to solve. We chose to focus on HF for several reasons. First, it is a condition treatable on an outpatient basis most of the time. Second, heart failure, unlike sepsis, which also has high readmission rates, is a condition that might lend itself more to a pilot program.

Gattis: Communication has broken down in health care. We are in the business of digitally connecting communities. If you look at a typical IC patient, this work really opened our eyes to the team approach that is required for this. HF not only requires primary care physicians and cardiologists, but also sub-specialists – an HF specialist, an HF nurse, imaging centers, case managers, pharmacists, physiotherapists and health agencies to residence. It’s a challenge in urban areas, but once you get down to the lower Rio Grande Valley and layer the social determinants of health and other unique challenges, a program like this offers a great opportunity. to shake things up. If we get ahead of these challenges, we can keep these patients healthier.

Helio: How was this program born and how does it work?

Magon: One of our larger hospitals came to us and said, “We have a readmission problem. We said, “We too. They are all our same patients. So how can we solve this problem? We were already working with LeadingReach in classic doctor-to-doctor referrals. I’ve seen what it can do.

At the same time, local emergency medical services launched a community paramedic program. The hospital administrator and I started developing this program. We created a plan where the hospital case manager would identify patients with HF while they were still in-house, and then we designed what we call a collaborative referral. This referral goes to the community paramedic. It goes to our care transition nurse. He goes to PCP. Then any other person we need to identify who is already known to be caring for this patient could be added to this electronic referral. Now we are all held accountable to each other. We have the highest level of responsibility.

We met with the other stakeholders—PCP, community paramedics—everyone agreed that this was a great opportunity. We have monitoring tools and education programs in place. Then we went to live.

The community paramedic visits the house twice a week. Our care transition nurse calls patients in between. We have a weekly huddle and ask the PCP to see the patient after discharge within 7 days. Our increased demand was to follow patients just before 30 days after discharge. The community paramedic is responsible for closing this landfill.

Healio: What are the results so far?

Magon: It’s a small number of patients, but we managed to bring our readmission rate down to 13.3%. We are pleased. Additionally, the local social services agency is also connected to LeadingReach. It was a huge advantage. If the team identifies a person who cannot afford medicine, we can refer them to the agency. Everything is integrated into the platform. We have been able to meet patient needs like never before. It’s been a wonderful piece to be able to come together in a new way.

Helio: You mentioned the readmission rates fall and respond to patient needs. Any other lessons learned since the implementation of this program?

Magon: For readmitted patients, we found that there was often no home support. When there is good support in place, and we support that support at home, patients tend to do better. We recognize this is a challenge.

Another challenge concerns end-of-life care. We want to help the patient and their family better recognize where they are and help them through. It is one thing to supplement your advanced directive advice, but patients need emotional and spiritual support. We recognize that we need to add that to the program, along with behavioral health support.

Gatti: What Dr. Magoon has just illustrated is the definition of the team approach to health care. You can’t build on programs like this unless there’s a good foundation in place to make sure patients get what they need. We can say that we have gone from 23% to 13%. Now, how do we approach the more difficult pieces? Some patients don’t have a support network. Some patients cannot or do not want to take charge of their health. Then there are those who want help but don’t have the resources. This program gives the PCP the ability to hold this network accountable. Our technology allows us to monitor and see what is happening. We can see who has staffing issues. We can monitor what’s happening on the network and identify staffing gaps and other challenges.

Helio: Are there any plans to develop this program?

Magon: We plan to expand and support additional diagnostics. In addition to HF, we would like to support monitoring for sepsis. It’s our other big primary diagnosis that results in a readmission. We want to add a broader profile of patients and then continue to add other community organizations, see if we can identify anyone to help us with behavioral health support, as well as the additional elements of the medical community in as a whole that can benefit our patients. It’s about the right care, the right time, the right resources.

Gatti: It is exciting for us to empower these thought leaders and leading physicians in the communities in which we work. We strongly believe in values-based care. We want GPs to have the ability to actively manage the health of their patients. If we can stop some of these problems at the PCP level and reduce the burden on specialists, we will have healthier communities. I love bringing our technology to the table and listening. Software never sleeps; we are always doing new things. We examine what Dr. Magoons around the world see as next-level challenges and support efforts to make these communities thrive.

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