Maintaining consistency and coordination of care is critical in order to improve patient outcomes. So when East Tennessee State University Family Medicine staff recognized that only a small amount of patients were being seen for follow-up appointments after being discharged from the hospital, they prioritized improving these numbers to enhance care delivery and outcomes across the board.
In order to address the challenge, like most health systems determined to achieve successful results, they started by collaborating. They formed transitional care clinic intraprofessional and interdisciplinary teams focused on leveraging health information and technology to create and enforce standardized processes, driving the optimal identification of patients requiring follow-up appointments. The ultimate goal was to improve communications and engagement among patients, providers and all staff involved in the process.
Collaborating to Improve Communications
To get started, the intraprofessional and interdisciplinary teams built an interface with local hospital systems to have an admission, discharge, and transfer feed into the electronic health record (EHR). This supported staff in identifying patients and ensuring notifications were sent as soon as the patient was admitted into the hospital.
Additionally, staff implemented a task list inside the EHR to prioritize and standardize the process through improved tools for patient communications such as patient portals. This made possible the customization transition of care notes and flowsheets inside the EHR, which eliminated duplication and optimized communications and processes.
As a result, East Tennessee State University Family Medicine improved transitional care management leading to improved care delivery, decreased admission and re-admission rates, and increased revenue. One of their major accomplishments included reducing readmission from 660 in 2016 to 159 in 2017 following implementation (read more about this in their use case).
HIMSS Davies Ambulatory Award
The HIMSS Davies Award of Excellence recognizes outstanding achievement of organizations that have utilized health information technology to substantially improve patient outcomes and value. The HIMSS Davies Award of Excellence is the pinnacle of the HIMSS Value Recognition Program and highlights organizations promoting health information and technology-enabled improvements in patient and business outcomes through sharing evidence-driven best practices on implementation strategies, workflow design, change management and patient engagement.
“We are so honored and thrilled to receive this recognition for the work we have accomplished in patient-centered care through health information technology in rural southern Appalachia,” said Julie M. Montgomery, clinical quality data manager for the Department of Family Medicine at East Tennessee State University Family Medicine. “Our investment in compassionate and efficient care through effective communication skills and standardized processes has led us to excellence in collaboration and innovation making an outstanding difference in the quality of care we provide to our patients. Receiving this award reminded us that we are on the right track building up our technical services to support the education that we provide to each and every medical residency class.”
“East Tennessee State University Family Medicine’s commitment to improving care delivery led to great success despite barriers created by operational partnerships that limit their ability to optimize their information technology system,” said Jonathan French, senior director of quality and patient safety at HIMSS. “Despite these barriers, East Tennessee State Family Medicine leveraged their information and technology platforms to standardize clinical pathways of care and engage all participants of the care process to improve care coordination significantly for their patient population. HIMSS is proud to recognize East Tennessee State University Family Medicine as a Davies Ambulatory Award recipient for their thoughtful application of health information and technology to improve the outcomes of their patients.”
East Tennessee State University Family Medicine will be recognized during the 2019 HIMSS Global Conference & Exhibition, which takes place February 11-15 in Orlando, Florida.
Learn more about how East Tennessee State University Family Medicine has embraced the value of health information and technology: explore two award-winning use cases.