Text Size: A- A+ Facebook Twitter LinkedIn YouTube

Breaking News



Format: 04/17/2014
Format: 04/17/2014


Allegheny Valley Hospital Establishes High-Risk Care Team to Reduce Patient Readmissions, Improve Quality

Friday, March 1st, 2013

Innovative Program Lowers Seven and 30 Day Readmission Rates by 30% and 13%, Respectively in First Year

Allegheny Valley Hospital (AVH) is taking a novel approach to improving the management of its high-risk patients and reducing unnecessary readmissions to the hospital. Hospital officials today said the establishment of a unique High Risk Care Team (HRCT) has significantly lowered patient readmissions over the past year among those most prone to complications that bring them back into the hospital after being discharged.

According to Thomas McClure, MD, AVH’s Chief Medical Officer, readmission to the hospital not only prolongs a patient’s recovery time but adds significantly to the cost of their care. Though some readmissions are medically necessary, Dr. McClure said as high as 30 percent are believed to be avoidable.

Upon evaluating AVH’s readmission rates and the number of high-risk patients it cares for, Dr. McClure and his colleagues developed an innovative strategy designed to reduce readmissions through a more proactive and better coordinated level of care across the patient’s entire healthcare continuum.

The High-Risk Care Team is comprised of a physician, case manager, emergency department nurse, psychiatric nurse and social worker. The team’s purpose is to identify patients that are at high-risk for being re-admitted; track their progress, coordinate care, provide patient education and offer any further assistance needed to help patients stay compliant with their care plans.

“The idea is that with more effective coordination of care, patient outcomes and overall quality will improve, and unnecessary readmissions will be reduced,” Dr. McClure said.

“High-risk patients represent about five percent of discharged patients, but account for up to 60 percent of healthcare cost in any given community. The High Risk Care Team’s multi-dimensional protocol improves the overall delivery of care to these patients, while lowering the costs associated with their care.”

The Team meets daily to assess each high-risk patient’s care plan. They offer patient education, assist with discharge planning, schedule follow up appointments with the patient’s primary care physician, outpatient physical therapy or other outpatient services, and facilitate getting the patient’s prescriptions filled prior to discharge.

After patients leave the hospital, the Team ensures that patients remain compliant with their care plan through regular phone contact and home visits.

“We have learned that readmissions often occur because patients are not compliant with their ongoing post-discharge care plan. Though reasons for that vary, we’ve found that psychosocial issues are frequently at the root of the problem,” Dr. McClure said.

Patients often simply need the reassurance from a nurse or other health care provider that they are still being looked after, said Lori Shotts, RN, a member of the HRCT.

The Team finds that many patients lack transportation to get to their next doctor’s appointment or to pick up prescriptions. To address those kinds of challenges, the team helps connect patients with a wide range of community programs that provide assistance with transportation, prescription delivery, house cleaning and other services.

“Our assessments look far beyond the patient’s medical condition to uncover any and all factors that may be barriers to them achieving an optimal health outcome and which may lead them back into the hospital,” Shotts said.

When the HRCT was established 12 months ago, the Team set a goal to reduce 30-day readmissions by 2.5 percent. They have exceeded that expectation by a considerable margin, lowering 7-day readmissions by 30 percent and 30-day readmission rates by 13 percent.

“The results of this initiative at Allegheny Valley have been simply outstanding,” said Diane Frndak, Vice President of Quality and Safety for West Penn Allegheny Health System (WPAHS). “The High Risk Care Team concept is a terrific example of how a group of talented, dedicated and visionary healthcare professionals can make a tremendous difference in improving the care of patients.”

In addition to Dr. McClure and Ms. Shotts, other key members of the High Risk Care Team include: Suzanne Suppers, RN, director Case Management, Sandy Moon RN, Emergency room case manager, Anthony Napoletan RN, Congestive Heart Failure nurse, Vicki McGowan, social worker and Rebecca Heinle RN, Palliative Care nurse.

The HRCT follows approximately 100 patients at any one time, including both inpatients and those receiving outpatient care at the hospital.

According to Dr. McClure, developing the HRCT to help reduce re-admissions was a good place to start in redesigning AVH’s patient care model to meet the standards of an Accountable Care Organization (ACO).

An ACO is a healthcare provider that embraces accountability for the quality, cost and overall healthcare experience of it patients. A central element of the nation’s Affordable Care Act, reimbursement for services under this new model is tied closely to patient care quality and efficiency.

Changes in government health care reimbursement based on the new standards of quality and efficiency will begin to take effect in July 2013.


For more information, contact:
West Penn Allegheny Health System
Tell us who you are:

What areas do you use on our website?*
(select more than one if it applies)

Did you find what you were looking for?

Would you refer others to our website?

Can we contact you for future questions?

CAPTCHA math question:* 3 + 9 =

Thank you for completing the West Penn Allegheny Health System website survey.
We value your feedback and comments.