Case Study

Reducing Hospital Readmissions at a 443-Bed Non-Profit Hospital

The Challenge

A 443-bed non-profit hospital faced significant challenges with high utilizers of its Emergency Department (ED) services. Patients with complex psychosocial and economic issues frequently presented with clinical conditions that led to inappropriate hospital admissions and readmissions. These frequent utilizers strained hospital resources, as busy hospitalists often treated symptoms without addressing underlying causes, resulting in a cycle of repeated ED visits and hospitalizations.

iStock-2152428487-[Converted]_56
iStock-2152428487-[Converted]_24

The Solution

To address this issue, the hospital partnered with IN Compass Health to analyze 30- and 60-day readmission data, identifying approximately 400 patients responsible for over 50% of the system’s readmissions. The hospital implemented the Inpatient Multi-Visit Patient (MVP) Program, a targeted initiative to reduce readmissions among this high-utilizer cohort through individualized care and proactive management.

Key Components of the MVP Program:

  1. Care Champions: Each group of 50 patients was assigned a Care Champion, a volunteer from disciplines such as case management, social work, respiratory therapy, pharmacy, physical/occupational therapy, or diabetic education. Care Champions integrated coaching into their regular duties, contacting patients weekly via phone or in-person to guide them through the healthcare system and social services network.
  2. Driver of Utilization (DOU): Care Champions were trained in motivational interviewing to identify the true drivers of ED and inpatient service utilization, addressing root causes rather than symptoms.
  3. Individualized Care Plans: IN Compass Health developed quality-driven intervention protocols, creating personalized care plans executed by a multidisciplinary task force of clinicians, social workers, pharmacists, therapists, and other stakeholders. These plans were activated and updated whenever a patient presented to the ED.
  4. Collaborative Oversight: Monthly meetings with the hospitalist program Medical Director, hospital care coordinators, and Care Champions facilitated program monitoring, problem-solving, and documentation of recommended actions in the shared medical record.
  5. Dynamic Patient Management: The top 50 patient list was continuously updated, with patients graduating from the program due to relocation, resolution of underlying issues, or passing away, and new high utilizers added as needed.
iStock-2152428487-[Converted]_52

The Result

The MVP Program delivered immediate and substantial improvements in patient care and hospital efficiency, creating value through reduced readmissions and enhanced, individualized care for high utilizers.

%
50% reduction in readmissions among top utilizers
%
47% savings in Medicare Spend per Beneficiary within the first 6 months

$847,600 monthly reduction in Medicare charges, equating to $10 million annually

Improved ED and inpatient care quality through consistent, proactive management of complex patients

By implementing the Inpatient MVP Program, the hospital transformed its approach to managing high-utilizer patients. The combination of data-driven patient identification, individualized care plans, and multidisciplinary collaboration not only reduced readmissions and costs but also improved patient outcomes and care quality. This case study demonstrates the power of targeted interventions in addressing systemic healthcare challenges, offering a scalable model for other institutions facing similar issues.

FROM OUR CUSTOMER

“Our work on the MVP Program to address readmission reduction has demonstrated that if you strive to understand the reasons for readmission in your patient population, you can develop better tools and processes to lower your organization’s readmission rate. IN Compass Health’s leadership and innovation has been invaluable in helping us achieve added value for our patients while reigning in hospital costs.”