During the two-year study period, the hospital implemented a set of reporting tools in its EHR system to notify clinical teams when high-risk Medicaid patients were admitted to the hospital or emergency department. Upon receiving these notifications, the integrated care teams connected with patients and their families to schedule and prepare for follow-up appointments and provide support throughout the care process.
Members of these specialized teams, comprising physicians, nurses, social workers and community health workers, also used technology to ease communication and coordination with each other.
According to the study, the multipronged intervention resulted in 50 fewer hospital admissions per month and 3,600 fewer bed days per year for the hospital’s population of more than 93,000 Medicaid-enrolled children.
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