With access to the electronic health records of the discharged patients the team was able to identify other gaps in care for HEDIS quality measures such as a lack of annual screenings or immunizations. EmblemHealth and MPG were able to update those treatments as they worked through post hospitalization issues.
Gillespie says that getting patients on treatment plans and up to date with existing treatment plans produced savings that were not quantified within the study.
And he says the effort also helped improve patients' quality of life by looking at patient needs outside of medical care, such as transportation issues and living conditions. EmblemHealth worked with community service groups to meet those needs.
Along the way, the program has increased patient satisfaction for the participating physicians as well as the health plan.
With a few tweaks the program is being expanded to other large multispecialty physician groups with close ties to EmblemHealth. For instance, case management staff that used to contact patients by telephone is now deployed to have more face to face contact with the patients.
Dr. Navarra Rodriguez, chief medical officer at Manhattan's Physician Group, says the value of the intervention team extend well beyond reduced admissions and cost savings. "Our patients are dealing with a very complex healthcare system. They rave about intervention team and how it makes them feel connected to our doctors and the health plan."