Health equity is the top priority for the Centers for Medicare & Medicaid Services (CMS). Health care improvement teams around the U.S. are working to identify groups of patients experiencing disparities due to systemic inequities and redesign systems of care to close those gaps and enhance equity in care delivery.
AnMed Health’s MVP program, focused on multi-visit patients (or “MVPs”) of the hospital, does just that.
The program, which began in 2019, focuses on reducing service usage of patients who have four or more hospitalizations or 10 or more emergency department (ED) visits in one year. AnMed partnered with Amy Boutwell, M.D., M.P.P, founder of Collaborative Healthcare Strategies, and applied the principles of Dr. Boutwell’s MVP Method initiatives. The program has been a success and the cost savings are making health care leaders take notice.
Initially, AnMed identified 51 patients as baseline MVPs to be the focus of the startup program. Suzanne Wilson, AnMed’s Assistant Vice President of Population Health, said these patients were costing the health system an average of $1.8 million per month in services. The goal for the first phase of the program, which began in June 2019 and ended in December 2019, was to achieve a 20% reduction of services. Results more than doubled, with a 52% average reduction in usage, and a cost savings of $522,000 to just over $1 million each month.
How They Did It
The key to AnMed’s success is its multi-disciplinary team consisting of various health care partners within the community. Team members examine the emotional and/or social determinants that may be affecting an MVP’s health and what may be driving the need for frequent visits to the ED. This information is used to develop a community action plan for each MVP who is then assigned a care navigator. For six months, the navigator meets with the MVP at least once a week, depending on his or her preferences, and connects the MVP with community resources to help him or her stay healthy and out of the hospital. The group of navigators meet monthly to discuss barriers and/or to set goals for their MVPs.
“The group offers support to a navigator who may be stuck with a complex issue,” Wilson said. “Collectively they work to determine the root cause of an issue and why that person continues to have return visits. There is a case review of the patient to figure out what can be done within their community to keep them healthy.”
The social and behavioral drivers that navigators often address include a lack of consistent housing or poor living conditions, lack of transportation and food, and low health literacy. Navigators have helped MVPs overcome these barriers by enrolling them in pharmaceutical and meal deliveries, coordinating home repairs and providing air conditioning units to improve living conditions.
“A lot of people just need someone to do the leg work for them,” Wilson said.
Engagement with MVPs slowed slightly at the onset of the COVID-19 pandemic, particularly during the period of widespread quarantine. Now, activity is increasing, and navigators have found their new normal connecting with patients via phone call instead of in person. Despite these minor setbacks, AnMed has plans to broaden the reach of the programs offered to MVPs including social services organizations and mental health departments.
Click here to access the “Readmissions Reduction Playbook,” which offers high-leverage strategies for hospitals and health systems. The Playbook, originally created in Virginia but applicable to providers everywhere, features a series of one-page summaries of key points, effective practices, and recommendations on readmission reduction strategies. This report is intended as another resource for readmissions reduction teams to use to help stimulate review and discussion as they work to develop and implement an effective portfolio of strategies to achieve readmission reduction goals.