PHILADELPHIA – After the first year of an innovative, five-year contract between the University of Pennsylvania Health System (UPHS) and Independence Blue Cross (Independence), the health system is reporting a more than 25 percent cut in hospital readmissions – the largest readmission reduction in both organizations’ history. As part of the first collaboration of its kind in the United States between a health system and a health insurer, the two organizations have launched a new slate of innovations to reduce the number of patients who return to the hospital within a month of going home. The contract provided that Independence wouldn’t pay for the resulting hospitalization in those cases.
The new contract, which took effect July 1, 2017, marked UPHS’s entry into a new way of working with Independence that is designed to encourage collaborative efforts by the insurer and health systems to improve quality of care and reduce health care costs for Independence members.
Many factors contribute to a patient’s likelihood of being readmitted, including disease progression, complications or infections that happen after an initial hospital stay, emergency room visits for management of chronic conditions, and miscommunications between patients or caregivers and medical teams regarding medications and other discharge instructions. These factors are often co-mingled, especially among patients with complex diseases like heart failure and cancer, or those who are managing multiple serious conditions. Making a dent in the number of patients who are readmitted is notoriously difficult: On average, hospitals’ typical interventions only cut readmissions by approximately one percent annually.
“To see such a drastic improvement just one year into our partnership with Independence serves as a great motivator to continue finding ways to bend the curve of rising health care costs,” said Ralph W. Muller, CEO of the University of Pennsylvania Health System. “That can only happen if we work together to keep patients healthier, and in the first year of our new model, we’re proud to have shown that we can achieve both goals.”
At the outset of the new initiative, Penn Medicine leveraged its electronic health record platform to identify patients at high risk of readmission, which includes many with cancer, heart disease, gastrointestinal conditions, and sepsis. Risk of readmission varied greatly across these patients -- patients classified with a high risk of being readmitted returned to the hospital 16 percent of the time, while patients classified as low-risk were readmitted less than one percent of the time. Stratifying patients based on readmission risk helped Penn Medicine to focus their efforts on patients at the greatest risk of readmission. During FY18, approximately 15,000 inpatient admissions were for patients insured by Independence.
New electronic medical record functions provided clinicians across Penn Medicine’s many care settings, including emergency departments, outpatient clinics, and home care, with access to real-time insights on each high-risk patient. The platform helped clinicians take proactive steps to reduce common post-discharge hurdles and make more informed decisions to keep patients well at home. For certain patients with complex medication regimens, this included use of pre-packaged medication boxes that were developed through a joint Independence and Penn Medicine initiative to remotely monitor and ensure patients took their medications as prescribed.
“These results are phenomenal and prove just how much we can achieve if we innovate together on purposeful programs to improve patient and member care,” said Daniel J. Hilferty, president and CEO at Independence Blue Cross. “We hope our experience reinforces to others in the health care field how important it is to work together to find solutions that can positively impact the quality and coordination of care and fight rising health care costs for patients and members.”
An analysis of data sourced by both Independence and Penn Medicine from before the new effort began showed that 40 percent of readmissions occurred within seven days of discharge, underscoring the need to improve patient education and expand access to outpatient follow-up care and home health visits. Now, patients who are found to be at high risk of readmission receive a call from a scheduler who assists in setting up all their follow-up outpatient appointments – typically combining them on the same day – even before they’re discharged from the hospital. Dashboards were developed to track follow-up visits at seven and 14 days after discharge to ensure patients receive timely follow-up care. Most patients now also leave the hospital with all their prescriptions in hand to avoid any delays in beginning new drug regimens.
Additional efforts included:
- Focusing on improved coordination between the inpatient clinical team and outpatient follow-up and home health care providers to close any treatment gaps that put a patient at a higher risk for readmission.
- Implementing more robust home care services to provide new opportunities for disease management and medication teaching after patients are discharged from the hospital.
- Monitoring high-risk patients remotely after leaving the hospital – a strategy Penn Medicine has also used to identify complications among heart failure patients and new mothers – to quickly identify and treat any problems.
- Reviewing patient data daily and having a care coordinator reach out to the patient if indicators are trending toward trouble.
As a result of the initiative, new services were also added to better care for patients without readmission. For example, data showed that many cancer patients were readmitted through the emergency room. In response, Penn Medicine developed an outpatient Oncology Evaluation Unit where patients can be seen as outpatients and effectively treated for common issues like dehydration. This program has been so successful that Penn Medicine is now reviewing other patient populations that would benefit from a symptoms management clinic.
“Research suggests that 25 percent of all readmissions are preventable, so what we’ve been able to demonstrate in this first year working with our partners at Independence is that we can implement strategies that substantially reduce our readmission rates and improve overall patient care,” said Patrick J. Brennan, MD, chief medical officer and senior vice president of the University of Pennsylvania Health System. “When we treat patients at or close to home, we are giving them the best chance at staying healthy and staying out of the hospital. By lowering our readmission rates we are improving the patient experience from the moment they walk through our doors until well beyond the time they leave the hospital.”
“Additional enhancements to care delivery, such as remote monitoring, virtual interaction, and intensive management in post-acute care and home settings, will further improve access to well-coordinated and satisfying care for our members and Penn Medicine patients,” said Richard L. Snyder, MD, senior vice president and chief medical officer at Independence Blue Cross. “The creative energy of our two organizations to improve the experience and outcomes of care is truly energizing and rewarding.”
UPHS’s contract with Independence includes the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital, and Chester County Hospital, as well care delivered in outpatient facilities, hospice, and home care services.
Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $7.8 billion enterprise.
The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report’s survey of research-oriented medical schools. The School is consistently among the nation’s top recipients of funding from the National Institutes of Health, with $405 million awarded in the 2017 fiscal year.
The University of Pennsylvania Health System’s patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center — which are recognized as one of the nation’s top “Honor Roll” hospitals by U.S. News & World Report — Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; Penn Wissahickon Hospice; and Pennsylvania Hospital – the nation’s first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine, and Princeton House Behavioral Health, a leading provider of highly skilled and compassionate behavioral healthcare.
Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2017, Penn Medicine provided $500 million to benefit our community.