Spotlight on Excellence

Spotlight on Excellence – Patient First Meets Goal of Reducing Readmissions

January 7, 2019

Photo of Patient First sign and building.

File photo of Patient First

Patient First is being highlighted as an exemplary practice in January’s “Spotlight on Excellence” feature for meeting and then exceeding a goal to reduce hospital readmissions by 20 percent (they eventually dropped the rate by 54 percent). A commercial payor challenged them to reduce their readmission rate from the baseline of 111 per month to 89 per month from May 2017 to March 2018. They met the 20 percent reduction goal three months early, and then continued to drop the hospital readmissions rate to 51 per month. Patient First, founded in Richmond, Virginia in 1981, currently has 258 clinicians practicing at 29 locations in Northern Virginia, Central Virginia, and the Tidewater region. They have an additional 45 practice locations in Maryland, Pennsylvania and New Jersey. Patient First is a member of Health Quality Innovators’ (HQI) Practice Transformation Network participating in the Transforming Clinical Practice Initiative (TCPI).

  1. What key issues did you identify that needed to be addressed to reduce hospital readmissions?

While Patient First uses a non-appointment visit model that offers convenient health care to patients 365 days a year, this can pose care coordination challenges. Pre-visit planning and huddles are not compatible with on-demand use by patients. We needed to determine how to connect with and care for our patients beyond the walls of our facilities. When they do come in for a visit, how can we maximize this time to comprehensively address their health?

  1. What changes did you make to meet these challenges?

We added Nurse Care Managers (NCMs) to expand our care by calling primary care patients who were recently discharged after an inpatient stay. This helped us support successful patient transitions of care back to their primary care physician within our goal of 48 to 72 hours after discharge. The NCMs were trained in active listening, motivational interviewing, and patient goal-setting to help patients benefit from short-term and long-term care planning.

Patient outreach can touch on a number of topics. An NCM can encourage and help schedule a follow-up appointment with a primary care clinician or specialist. They can review changes to medication and discharge instructions to make sure the patient and/or caregiver understands their health care action plan. An NCM can also establish a chronic disease care management program including goals that were co-developed with a patient.

Patient First created an NCM module, accessible through an electronic health record system, to help NCMs document outreach, manage care plans, and communicate important information to clinicians practicing at our centers. We compiled patient reports within these modules to maintain valuable health information about patients outside of their visits to Patient First and identified who needed outreach from an NCM.

  1. What reactions did you see from your patients and clinicians?

Our patients appreciate having access to someone who can help them navigate multiple care settings and be an advocate for their health care. Patient First’s clinicians greatly benefit from the team-based approach that dedicate the time and resources to managing complex patients.

  1. After the success of this initiative, what are your next steps?

Based on these results, we’re expanding and adapting our transitions of care models to encompass all of our value-based programs. Our NCMs will continue to proactively contact patients to help them manage transitions of care, engage with high-risk patients or those with multiple chronic conditions, and close gaps in chronic and preventive care.

  1. What has your experience been like participating in the Transforming Clinical Practice Initiative (TCPI)?

Our past efforts to provide value-based care focused predominantly around commercial populations for specific health plans. The TCPI initiatives have provided a wider perspective on how to improve quality and reduce waste across all populations through systemic changes. Our interactions with the HQI team and TCPI provide access to additional best practices that have been effectively implemented across the country. We benefit from analyzing and identifying effective components of these methods and implementing them in our organization in ways that are scalable across our location footprint and are compatible with our company’s mission and cultural values.


Graph showing Patient First dropping its readmissions rate by 54 percent in less than a year.

Patient First reduced its hospital readmission rate by 54 percent in less than a year, meeting then exceeding the initial goal to reduce hospital readmissions by 20 percent.

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