Reducing Readmission Risk Through Whole-Person Design Corewell Health

Corewell Health is a $15 billion not-for-profit health care system that serves three geographical regions with 300+ ambulatory locations and 5,000+ licensed beds across 21 hospitals. Corewell Health also includes Priority Health, a provider-sponsored health plan serving more than 1.3M members across the state of Michigan.

National averages show that within 30 days of a hospital discharge, approximately 20% of patients are readmitted to the hospital and 27% of those readmissions are for a reason that was considered preventable with proper management. On average, this costs the US health care system around $17B per year. 1,2,3 In early 2021, Corewell Health in West Michigan embarked on an outcome improvement journey to reduce hospital readmissions for patients with both public health care insurance that qualified for the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program (CMMS HRRP) and privately funded value-based contract arrangements.

Adopting the Scaled Agile Framework for Enterprises (SAFe®), Corewell Health developed cross-functional teams comprised of individuals from operations and digital services that quickly adapted to changes, new insights and information, embodying transparency, alignment, respect for people, and continuous improvement. These teams aligned around a common purpose, vision and understanding focused on the problem first, and then allowed the best solution to emerge through iterative end-user feedback and person-centric development. With this new collaborative agile approach, the teams were able to maintain continuous delivery of viable, desirable, feasible and sustainable innovative solutions.

Using predictive analytics and patient indicators for target populations within Epic, the electronic medical record (EMR) software used by Corewell Health, to identify patients at the highest risk for readmission, additional coordinated resources were deployed to focus on those individuals with unpredictable recovery journeys and would most benefit from support of care managers to provide interventions focused on transition support and whole-person care. New documentation tools were also developed to facilitate the targeted nature of this intervention.

Corewell Health learned that customized care that is acceptable to the patient is imperative to success where blanketed solutioning is not nearly as effective. By utilizing predictive analytics and patient identification tools, the newly formed transitions of care team was able to focus their efforts on patients who most needed post discharge support.