Managing preventable health risks and hospital readmissions is challenging for clinicians and care managers when they are limited by incomplete information. A study published in the Journal of the American Medical Informatics Association (JAMIA) reported a reduction in hospital readmissions when primary care providers were notified of a patient’s hospital admission and discharge.
Imagine if those hospital event notifications were enhanced with clinical data that allowed for a focused response to patient follow. Reliance is making it possible…enabling the care team to establish notification reports that can be managed as part of the workflow or set to trigger individual messages for more immediate risks. Some example include:
A Diabetic patient is admitted to the emergency department (ED) with blood pressure of 160/90 and HbA1c of 9.2%. Staff in the PCP office are notified of the admission, vitals and lab tests indicating increased risk for adverse events from diabetes and hypertension. With the benefit of this information, an appropriate care plan can be implemented to support the patient’s transition from the hospital into the primary care setting. Clicking a link in the notification, allows the staff member to review the patient’s community chart in Reliance, including the last care summary from the cardiologist and nephrologist; making it easier to coordinate the patient’s care plan across his care team.
A care manager at a health plan responsible for ensuring healthy pregnancy outcomes for the plan’s members wants to know when a member becomes pregnant and any risk factors that may develop. The care manager sets a notification for positive pregnancy tests as well as risk factors, such as a pregnant member’s blood pressure, urinalysis and glucose levels showing risk for pre-eclampsia and gestational diabetes.
 Reference: Hospitalization event notifications and reductions in readmissions of Medicare fee-for-service beneficiaries in the Bronx, New York; Mark Aaron Unruh Hye-Young Jung Rainu Kaushal Joshua R Vest. J Am Med Inform Assoc ocw139. 07 October 2016. DOI: https://doi.org/10.1093/jamia/ocw139