Case Study: St. Joseph Healthcare sees dramatic improvement serving high-risk population with HealthInfoNet

Harnessing analytics has led to big gains for Maine-based health system to dramatically reduce readmissions, identify high-risk patients and utilize real-time data.
By Jessica Davis
09:54 AM

St. Joseph Healthcare has already deployed analytics software to reap big gains. Chief among those: dramatically reducing readmissions, helping clinicians discover high-risk patients, improving care management and utilizing real-time data.

"Analytics streamlines my ability to capture the highest risk patients, rather than trying to track down information," said Jessica Taylor, RN, care manager and clinical lead at St. Joseph. "I can focus on patients with a higher risk for readmissions, instead of casting a wide net. It's difficult, as a manager, to get information while patients are still admitted in the hospital," she added. "But since the information is updated every evening - I can reach out to the patient before they leave the hospital."

In January 2015, Bangor, Maine-based St. Joseph became the first healthcare institution in the state to use analytics from across the state's health information exchange, HealthInfoNet, for its daily operations.

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Maine was one of the first states to achieve information exchange among all its hospitals statewide. The HIE connects nearly all of Maine's 1.3 million residents, by collecting clinical information from 32 of the 36 state's acute care centers and 376 ambulatory providers. This allows all organizations involved with HIE to contribute and utilize the data.

While many healthcare organizations use analytics software for some aspect of its procedures, the HealthInfoNet stands out, as the analytics program sits on top of the HIE. That way, clinicians can access real-time data from all hospitals connected to the HIE, said William Wood, vice president of medical affairs at St. Joseph.

Caregivers access the data entered overnight as their first task in the morning, said Taylor. In this way they can establish workflow charts, plan discharge paperwork and determine high-risk patients.

One of the biggest uses of the analytics software for St. Joseph has been to reduce readmissions, Wood said. They've dropped below 10 percent – about 5 percent below the state average. That includes a 15 percent drop in emergency department readmissions in a six-month period.

"Our readmissions are low, not because we're keeping patients longer," he added. "We're getting them home and using the tool to find those folks at risk to keep them home."

HealthInfoNet's vendor partner, Palo Alto, California-based HBI Solutions, proposed the idea of analytics to St. Joseph during a time when Maine Governor Paul LePage was vetoing Medicaid expansion bills, said Wood.

"We were struggling to find those without insurance and then layer in the extra care management for these patients," she said.

"When the tool was first introduced, I immediately checked for high-risk, uninsured patients," he added. "We've worked the list and now the high-risk patient admittance has dropped dramatically – now it's fewer than 100 each year."

"The 'frequent flyers' and high-risk patients, we know who they are," Taylor said. "They're right in the forefront of our tool. We can be proactive instead of reactive with care, when before we were waiting for these patients to come to us."

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It's all about filling in the gaps and meeting those patients typically lost in the shuffle, said Wood.

St. Joseph is also reaching out to help providers who send their patients to them for care, ensuring they're making the most of the technology.

About half of our admissions come from Penobscot Community Health Care, for example, which covers about 40,000 patients, Wood said. "They have a very large care management program and they're just starting to use analytics tools. We can step in and make sure they're leveraging the analytics tools, as well."

"I think if we didn’t have the tool, our care management department would be dramatically different," Wood said. "It's had a big impact on how we handle care management, into a clear and precise mission."

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