Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. One of those existing challenges that has only become extra tough is readmissions. Because let’s face it: readmissions cost us not only dollars but time and human resources—all of which have taken a dent in the last few years. In this episode, we are joined by Dr. Tricia Baird to help us get ahead of readmissions. Dr. Baird is the Vice President of Care Coordination at Corewell Health West, where she and her team published the paper “Reducing Readmission Risk Through Whole-Person Design.” She shares with us what they found from their study, revealing the crucial role of educating patients to advocate for themselves. Dr. Baird also talks about overcoming disparity across the organization, employing a multidisciplinary team, and utilizing technologies. Tune in to gain more information about supporting your patients and getting them their best health.
Get a hold of Dr. Tricia Baird’s paper, “Reducing Readmission Risk Through Whole-Person Design,” published at the New England Journal of Medicine Catalyst, Volume 4, Issue 1.
Listen to the podcast here
Getting Ahead Of Readmissions: Reducing Readmission Risk With Dr. Tricia Baird
We had an amazing and energetic conversation with Dr. Tricia Baird. It was great. We always say this but that was way too short. We just scratched the surface.
There’s another opportunity to speak to her in the future to carry it to the next chapter.
How would you summarize what we just talked about from your perspective as a hospitalist who is deeply involved in these complex care patients?
They have tackled what a lot of other organizations are fearful of taking a look at and sometimes feel completely overwhelmed as they stare this down the lane. They have been able to make meaningful changes. That 24% down to 7% reduction is fantastic. They’ve got some real applicability in how they’re using their resources and the benefits they’ve yielded from it, even down to what it looks like in a meeting with the people who have to make it all happen.
This is a fantastic episode because we’ve seen the results. You can see the end from the beginning and how it can be applied. I would highly recommend it because it gives a starting place for organizations to tackle these. We’re not talking about esoteric sorts of things. We’re not talking about something limited to the warm and fuzzy. These are hard numbers that organizations are looking at that are fiscally applicable to the outcomes of their patients and people in their communities. What wealth. I would like to see it carried forward to future conversations, not only for what people can accomplish but to understand a little bit more about the differences between American and European football.
That’s a great teaser. This is plugging holes in the bottom of your revenue bucket. Please, get paper and a pencil, or how you take notes, get ready, and buckle up for a great conversation with Dr. Tricia Baird.
We’re having another very interesting conversation that we think you will be interested in. We’re talking about barriers and solutions to patient throughput. Our subtopic is getting ahead of readmissions. This is a super important topic, given the struggles and challenges that you all are facing in terms of profitability in your health systems. This is a hugely important topic simply because of how much readmissions cost in each health system in not only dollars but time and human resources.
For us to fully understand this, we have been very fortunate to find an expert in this field, Dr. Tricia Baird. Tricia is Vice President of Care Coordination at Corewell Health West. We’re going to find out a little bit about that. Some of you have heard about Corewell. It’s from my home area in West Michigan but they have now expanded all across Michigan. I want all of you to hear from Dr. Baird about Corewell and what their challenges and opportunities are. We will get past that and get right into the conversation but let me give you a little background on Dr. Baird. She is ideal for this topic because she has both payer and provider experience.
She worked with Priority Health, one of the largest health insurers in the state of Michigan. It’s owned completely by Spectrum Health. That used to be Butterworth. She has got experience as a physician in rural and suburban family practice, hospital care, nursing home rounds, and obstetrics. When we did our little pre-session, I was fascinated by the amount of experience that she has. That is so rare. Without further ado, I want to welcome to the show Dr. Tricia Baird. Dr. Baird, thank you so much for taking the time to speak with us.
Thank you, Roger. It’s a pleasure to be here.
We also are joined Dr. By Dr. Darin Vercillo, my colleague and friend who is the Founder of ABOUT Healthcare and frequent co-host. Dr. Vercillo, thank you so much for being with us as well.
It’s great to be here with you as always, Roger.
Darin and I are going to be interviewing Dr. Baird. I don’t know if we’re going to have time to get any questions in because she has so much information to talk about. Dr. Baird, you and your team at Corewell in Grand Rapids in West Michigan have been published in the New England Journal of Medicine Catalyst Innovations in Care Delivery a very interesting paper, Reducing Readmission Risk Through Whole-Person Design. We want to get into that but before we do, would you take a couple of minutes and talk a bit about Corewell? Our audiences are going to be interested in hearing about this phenomenon.
We are in the midst of that rebranding and name change. In February of 2022, Beaumont Health, which is well-known in East Michigan, and Corewell Health in West Michigan came together with a for-Michigan and by-Michigan commission and later announced our new name of Corewell Health. You hear us using our Corewell regional names interchangeably with those legacy branding names, Beaumont Health and Spectrum Health in East and West. In the South, what people had formerly known as Lakeland Health System forms the South region.
We have now over 20 acute care sites, over 300 ambulatory sites, 60,000 employees, and 6,000 providers employed but a much larger independent relationship of clinicians very focused on aligning with our President and CEO Tina Freese Decker on a journey for value-based care for diversity, equity, and inclusion for creating the kinds of communities that health contributes to in a meaningful way.
It is indeed the largest health system in Michigan.
That is true.
In the old days, we used to talk about the number of beds. There are many other metrics that are more critical and descriptive but you have over 5,000 licensed beds. That’s amazing. That’s a huge system. Congratulations.
Congratulations and best of luck. Not to jump into questions too quickly but it’s fascinating to me when you get a geographic area that’s so expansive by the geographic spread alone. You must encounter, to your point, such economic and social diversity in the organization. It doesn’t have to be right at the second but in your explanation and our discussion, I would love to hear how you address reducing the disparity.
We have seen that in other states during the pandemic, Arizona, and other places. There are ideas on how you’ve overcome where people are located rurally or in places where they don’t have access to care and how you can get them the care and overcome that diversity and disparity across your organization. I would love to hear what you’ve done to do that.
Honestly, the care coordination teams have been like a family reunion. We have met the other half of our teams as we align across the regions. They have solved several problems in other regions that we were hoping to get into, and the reverse for us. There’s lots of sharing and collaboration. Speaking of collaboration, we have learned a lot in the last few years about internet access in rural spaces, particularly from schools.
Our school districts in Michigan did a great job of mapping a lack of functional internet access for us in the rural regions as several of our rural school systems could not do online school but instead had to send school buses around with paper packets. Everywhere that families were doing paper packets because they didn’t have enough video feed, we followed on with particularly stronger infrastructure evaluations for those patients in those rural areas. For those of you who have not enjoyed the beautiful and short Michigan summer, the other half of that is lots of snow in the winter.
Sometimes it’s not only an internet issue. It’s plowing the driveway and being able to drive out over several feet of snow. The lack of internet in rural spaces and road infrastructure becomes a critical issue for our complex patients. It becomes a readmission issue. We are learning a lot every six months as we meet new people and collaborate outside of the healthcare sector as well. We will come back to that. It plays in a lot of our planning.
It’s wonderful to talk about telemedicine doing a 180 to telemedicine but if you don’t have the bandwidth, equipment, capability, or internet capacity to do it, it’s worthless. That is very interesting to see how you’ve been able to map the school districts and follow along. What a great increase in the capacity and resources for these communities that you all serve. That’s fantastic.
Thank you, Darin, for that question. Tricia, why don’t you talk about the paper that you put together? In my introduction, I failed to mention that Dr. Baird also is responsible for these multidisciplinary teams of caseworkers, social workers, RNs, and a host of other services that are provided post-discharge. How did you employ that multidisciplinary team to do this very extensive study over twenty months or so? Why don’t you talk about that? It was great.
We started with a focused identification in real-time. We believed that there were a smaller number of patients who had a much greater risk of readmission than the general population of the adults we discharge in the West region. You were talking about 5,000 beds. In the 40% of beds in our West region, we discharge about 2,000 adult inpatients a week. That is a tremendous amount of patient flow.
We felt that it would be better to find the people on discharge who we were most worried about moving forward and support them in a very different way. The paper describes what happened. We cut the total population readmission rate in half by engaging with less than 1/5 of the population that was moving out the door. We have value-based contracts. We’re trying to best deploy the limited resources that we had available as the pandemic shifted resources here and there.
Our focus population was the value-based contract population, and then finding those inpatients in our value-based arrangements who were at particularly high risk of readmission. What that gave us was a natural control group experiment for all of the fee-for-service patients who were moving through the same environment and set of risks.
Our risk tool scores every patient that’s under our care. We had a running control group separate from the intervention group that lent to the case study methodology that we were able to describe but with the operating focus on who most needed that complex relationship, we found that those patients at the highest risk weren’t always at risk of readmission because of their medical diagnoses or medications alone. Many of you have heard the statistic that only 20% of a person’s health outcomes are based on their direct medical care.
This complex group is a great example of all the things that can happen in your life or environment that interfere with that readmission work or readmission journey. These nurses, social workers, and community health workers are ready for anything. They are ready to initially make contact with the patient the day after they go home and offer services for free, “Can we help along with what you’re trying to solve? What is your agenda? What’s most important to you about regaining your health?”
From a leadership standpoint, we gave them coverage to say that whatever the problem is, you’re empowered to solve it if it’s groceries, transportation, or, “I don’t understand my instructions,” or more often, “I got three different sets of instructions from different offices that conflict. What do we need to do to sort out the three most important things for the next few days? In three days, we will do that again. What are the three most important things for the next few days until the plan starts to clarify?”
The general population had about a 12% readmission rate. The group that we were able to focus on had a 24% readmission rate. We were able to bring it down to 7% by following along with the team over those 30 days and teaching them how to advocate for an appointment. If your follow-up instructions say, “Come back in three weeks,” and you call the office and they say, “We have an appointment in eleven weeks,” do I push? Do I not? What do I say when I push?
With all of those teaching along, helping them make appointments, and helping them clear the barriers, it doesn’t take long before people start to show that they understand how to solve problems. It goes from demonstrating to coaching to developing independence. We’re finding that readmission reduction is continuing after the intervention as people have learned those skills to advocate for themselves.
Let me get this straight. I want to make sure our audience doesn’t miss this. In your paper, you talk about how readmission-related care accounts for approximately $17 billion of potentially wasted healthcare dollars in the US. Some of these readmissions are necessary but it’s a lot of money. That’s an annual figure. The general population has a 12% readmission rate. You’re trying to predict who’s at the most risk. The population that you studied was a 24% readmission rate. You reduced that to 7%.
This is what’s particularly interesting. We were trying to cut that 24% in half. We were looking for 12%. The highest risk group had a 24% readmission natural rate. The middle-risk group or the second quintile had a 17% natural readmission rate, and then in the bottom 60%, 3 out of 5 of every patient we discharged had a 7% readmission rate. We were pretty excited when that 24% fell to 12% but then it kept dropping. It’s fascinating that it stopped at the 7% readmission rate that our low-risk population stopped at.
All of us who are involved in inpatient care are aware that we are in a dance with biology. Some people need to come back to the hospital but when we got back down to that 7% or that natural low-risk rate, that may represent a biological occurrence in the population. Sometimes you need to come back but it felt good to close that entire gap.All of us who are involved in inpatient care are aware that we are in a dance with biology. Click To Tweet
That’s interesting that you identify that baseline risk. In my practice as a hospitalist, you see that recurrence of people coming back in a natural cadence, not necessarily because there was a mistake made, there’s non-compliance, or all the things that we blame readmissions on but the natural disease course and state will bring people back from time to time.
I’m curious. We look at things like that. We say, “There’s non-compliance. A mistake was made. There wasn’t a follow-up. It slipped through the cracks.” What cultural mentality change have you seen as you’ve looked at this? I don’t know anybody that would believe, “We can take high-risk and intermediate-risk people and bring them down to baseline risk.” It’s never going to happen. We reject that outright because we have dealt with this our entire careers. Have you seen a mind shift or a culture change in the way people think about this, especially on the physician side?
That’s fair. Darin, first of all, let me flip that statement. If there’s nothing we can do for these people who are coming back, then we have decided that we have no influence or impact on this conversation. That may be true but that’s bad news for our job security. Why are we showing up in healthcare if we think there’s nothing that can be done? Knowing that wasn’t an option, what can we do? What conversation can we have? Once we outright flip the implicit assumption in that statement, “There’s nothing we can do,” then why are you coming to work tomorrow?
Let’s imagine we’re coming to work to make a difference. What can we do? We start talking about the phrase non-compliant, which is a very judgy word. Unfortunately, it should be a judgment of the people who are using it, not the people it’s being used on. We had a lot of conversations about this fact. Inside a medication list and a problem list, you are not seeing the whole person.
Those stories may exist but they’re frequently not documented in the chart. They’re not structured in all those sidebars that we work in but there is a story that exists, and just because you don’t know the story doesn’t mean it’s not present. We spent quite a bit of time talking. If you don’t understand how a reasonable person could have gotten here, you haven’t listened enough.
If I make you hungry and tired and put pain in several parts of your body, you’re going to make a whole different series of decisions. If you’re worried for someone you love who is tired, hungry, or having pain in several parts of their body, that’s a whole different mindset of decision-making. I cannot tell you that I would make all the same decisions that the people we’re serving would make but if you don’t understand how a reasonable person could have made the choices that got us into the space we’re in, you’re not ready to sit with them with the problem and help.
We talk about that with providers a lot. It’s amazing to me. The people I argue with the most are in the executive suite or clinical leaders. Every time I get into one of those crucial conversations, within a few weeks, someone from that meeting comes back to me to tell me that between our disagreement and the follow-up, someone in their family got very sick, and they can’t believe how hard it is. Welcome to the fun that is wanting everything fixed for the person you love or yourself as quickly as possible.
In my opinion, people are trying to solve the problem they can see with the resources they’re holding the very best they can. That can sometimes create a particular run of decision-making but if we can’t see it from the perspective of the people we are trying to help and serve, then we are not ready to sit in potential solutions with them. There are different conversations that we have with different stakeholder groups but this gets to empathy, perspective-taking, and whole-person care. Sometimes they’re also patients but they are people, and so are we. We have to start with that over and over.
That’s a great line of discussion. It’s a great question. Darin, thank you. I’m thinking back. I’ve been in healthcare a lot longer than the two of you. I remember days of a long length of stay. We didn’t have any collars on the length of stay. They stayed as long as they needed to stay, which would obviate readmission because they had three admissions worth of length of stay.
We have compressed that now. We’re sending people out earlier, which means that the work that we have to do in the hospital and when we start is far more intense than it used to be. Tricia, you talked in your study about asking nurse managers to focus attention on this high-risk population. That alone is something that was probably helpful even if you didn’t do all the other interventions. If you focus people’s attention on the right thing, you’re going to get results.
There are many ways to focus on a particular population and, depending on your population of focus, match resources to it, whether that’s surgical bundles, the highest risk of medical readmission, or value-based contracts. It doesn’t matter in my mind how you focus. It’s that you had a mindful focus with a resource match.
I’m going to push us along here. This is so interesting but for the sake of our audiences, I want us to get to a couple of things. One is how you get started on this. You said that your goal was to make this repeatable and scalable because you have such a large system now. Can you apply this everywhere throughout the system and get very much the same results? Please talk to us about that. Hopefully, you will weave it into your football analogy. We talked a bit about this in preparation for this. I’m focused on a couple of those elements but please talk to us about how you would advise somebody to get started to try to employ this approach.
That makes sense. A starting point is in front of all of you. Unless you are a critical-access hospital, your hospital participates in the CMS Hospital Readmissions Reduction Program. The HRRP has been going on for decades. It’s a super fun game. We all play with each other. If your hospital either pays a revenue penalty in the HRRP program or has a publicly reported performance in six diagnoses that do not meet the expectation of your board, your executive team would love to hear from you about how to focus on those patients.
Most of the time, they are between 0.5% to at most 2% of your entire inpatient population. They’re traditional Medicare patients over 65 with a limited set of diagnoses. That is a great population to get started on to practice focused real-time identification and focused intervention and reduce that readmission. That’s a great start because I often say that readmission work is very much like football in several interesting ways. I don’t think that football is a big game of strategy. It’s a game of consistent and mindful execution, and so is readmission work.
Any given Sunday, it depends on what people’s execution strategy is on the field and how they respond to what the other team brings to the field. We talk about readmissions in much the same way. It is very much, “How are we doing this? How are we improving this? How are we coordinating the team?” Readmissions and football are somewhat similar.
We talked about that. I love that analogy because what differentiates most sports, not just football from mindless other activities is that there are two elements. There’s the scoreboard and the time clock. In healthcare, we have the scoreboard and the time clock. That ensures that every spectator, every patient, every physician, every administrator, and everybody can take a score or know what the score is if they choose to by looking at those two elements. What are the scoreboard and the time clock in your work?
At the time of discharge, we’re identifying who’s at the highest risk to come back. All of us are familiar with this concept. This is a 30-day readmission window. Payer data is typically 4 to 6 months lagging. Many of our internal hospital quality systems will identify things at 6 or 8 weeks. Neither of those timeframes will help you in a current 30-day interdiction. Figure out your focus. I would encourage all of you to lean into a timely and broader specificity of identification.
We are willing to identify 130% of the patients that will eventually fall in that 100% cohort if you can tell me who they are on the day of discharge because when I call them all the day after discharge, I will figure out the 30% that doesn’t need to be in there. To have 100% accurate targeting six weeks after discharge does nothing for a 30-day prevention cycle.
That time clock is incredibly helpful to be in the work of now and this week. Our particular focus on the timing of that identification is to find a group for whom my team or the resources you’re going to send are actionable. If it’s a CHF focus group, you can send cardiac rehab the same as you could send the cardiology office or nurse care managers. If it is an oncology group or a post-operative group, you either need to send nurse care managers, general support, or content experts that help. Those are silly examples but often, we identify a group and then send a resource that doesn’t match it.
This is not a hand-holding exercise. This is a very intentional problem-solving exercise. You need to send people with the skills and the empowerment to solve those problems. That’s the time clock. I already mentioned the scoreboard. Our traditional tracking systems are built to be accurate for payment with the payers 4 to 6 months out and accurate for quality reporting with our internal teams 6 to 8 weeks out. They are prioritizing accuracy as they should. That’s not what is happening here.
To make sure we’re being sensitive and inclusive of the population that is at the highest risk, we’re going to slightly over-identify to get everyone in the group but that also gives us real-time tracking. If any of you enjoy process improvement with PDSA cycles, that real-time data is invaluable. There’s a six-month data payer lag. I don’t care what happened anymore last Halloween but if that’s the most updated data that you’re showing me, how am I supposed to fix anything? What we need to do to be in the time clock also gets us into a scoreboard that is much more amenable to process improvement.
Tricia, you’re singing my song and speaking my language here with ABOUT Healthcare. Over the years, we have been involved in real-time data, tracking, and surveillance. There’s a great project that I’ve seen unfold. You mentioned bundle care management and staying on top of those patients and identifying risks. I want to peel back that layer and unpack that a little bit. What are the technologies that you’ve seen in play? We’ve got systems that take data and under algorithms that try to identify high-risk patients.
We have systems that will put patients into calling groups. You have dedicated call centers reaching out to them. It’s a rubber-meets-the-road execution to your point on the field of how we make sure people don’t slip through the cracks. We’re not being subjective on this. Talk about the technologies, the real-time data visualization, and the way you’ve made this happen so there’s perhaps less burden on the shoulders of case managers, and you can balance out this workload of understanding and contacting these patients and making it all happen.
To continue the football analogy, this is part of reading the field and calling an audible. This play is set up differently than what we had planned before we snap the ball. We frequently talk about the quarterback. That was a more amenable analogy than, “Who’s flying the plane?” Both of those are great. These are big processes with zero tolerance for failure.
It is essential after you get any focused identification of the patients, meet them, and make relationships, that the entire 30-day period needs some technology communicator. We’re learning that patients want it to be asynchronous and technology-driven. I don’t know why we call our remote computers phones. I don’t know how often people do a verbal call on them anymore but there’s a whole lot of texting and searching.
Our teaching conversations help patients to understand, “These are the next three most important things that you and I need to get done together for you.” Whether those are your life priorities or a couple of health priorities, they’ve got those top three things. When patients are clear and empowered, their ability to use asynchronous communication allows my team to do a structured outreach maybe twice a week in these high-risk patients but they can trigger or call for a follow-up or an escalation several times a day or several times a week if that’s what they need.
It’s having that ability to communicate for the patient outreach to that clinical quarterback to be able to communicate those updates across all of the allied health team and clinicians that are wrapped around. We’re handling that back-end process and the things that ABOUT would do inside of the clinical interface to keep things clean and clear with the patient with those two connections.
That patient is able to reach back to us asynchronously instead of having to sit at home and hope a phone call comes through. It may be tomorrow. It may be in four days. They’re out at therapy or appointments. They’re out trying to get better but they can see a text wherever they are. Our team coordinating backstage without passing those communications through the patient increases their sense of trust. We do seem to know what we’re talking about with each other. Those two vertical and horizontal communications have been essential to delivering that execution.
To follow up or continue with the football analogy, we have gone into overtime, and we have to bring this to a close. Tricia, what a wonderful conversation. We just scratched the surface of all that you and your team have done. Congratulations to you, this wonderful multidisciplinary team of caregivers, and Corewell too. All the best to you in implementing everything that you’re doing for the state of Michigan and all of your patients and staff. This has been great. Thank you so much. What’s the best way for them to get ahold of your paper so they can read this?
You can go to the New England Journal of Medicine Catalyst. We are in Volume 4, Issue 1, the January 2023 Issue of the New England Journal. I would be happy to continue this conversation. Roger, we didn’t even get to the difference between American football and European football. That happens in readmissions too. It was a true pleasure to have a chance to talk with you. I know how many of us are all working on the same problems and how good it feels to support someone’s recovery and see them thrive and find their feet and their best health. It’s what we all get out of bed for every morning.It feels good to support someone’s recovery and see them thrive and find their feet and best health. Click To Tweet
Your enthusiasm is inspiring with the fact that you love what you do. I’m sure that your team members love working with you. Thank you so much for the great work that you’re doing. All the best for the future. Darin, thanks for your great questions. We have to bring this to a close but please reach out to us if you have further questions or if you would like to get in touch with Dr. Baird. Perhaps we’re going to have to have another episode talking about the differences between American football and European football. There’s a lot to talk about. Thank you so much. Thanks to our audience. We strive to make this as interesting, helpful, and actionable as we possibly can. Tune in next time. Thanks
- Corewell Health West
- ABOUT Healthcare
- Reducing Readmission Risk Through Whole-Person Design
- CMS Hospital Readmissions Reduction Program
About Dr. Tricia Baird
Tricia Baird is vice president, care coordination, Corewell Heath West. Corewell Health is a $14 billion not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people providing care and services in 22 hospitals and 300+ outpatient locations and post-acute facilities—as well as Priority Health, a provider-sponsored health plan serving over 1.2 million members. In this role, Tricia leads inpatient, transitional and ambulatory care management, as well as utilization management across the west region. The care coordination team uses registered nurses, social workers, and community health workers to focus on the management of complex disease patients and transitions of care. The team integrates specialty and regional care, along with connections to independent providers and community organizations, to support high-value care for West Michigan.
Dr. Baird will share her perspective and insights on this important theme and topic, providing practical suggestions that can be applied immediately.