Improving Care Delivery for FQHC Patients

Leveraging Automated Patient Outreach to Engage Patients Across Two-Dozen Hospitals and Health Systems

Chase Brexton Health Care is a Maryland-based federally qualified health center (FQHC) providing health services to thousands of Maryland residents each year. With a mission to deliver compassionate and quality health care, Chase Brexton looks for proven solutions to assist their patients along their healthcare journey.

CHALLENGE

Research demonstrates that following up with patients post-discharge plays an important role in improving patient outcomes. Chase Brexton employed two non-clinical care coordinators to follow up with patients after a hospital or ER visit. In order to reach an even higher percentage of their patients, Chase Brexton needed an effective solution to engage patients within 24-28 hours of being discharged from one of 26 Maryland facilities.

SOLUTION

In November 2015, the FQHC launched CipherOutreach. To ensure the right patients receive follow up, CipherOutreach integrates with the Maryland state Health Information Exchange (HIE). Patients who have seen a Chase Brexton PCP within the past 18 months receive an automated outreach call within 24-48 hours of discharge from any local facility. Patients indicating a concern on the calls are triaged to the care coordinators, who resolve the issues within two hours of receiving the alert.

RESULTS

Since the implementation of the program, more than 1800 patient issues have been resolved and the FQHC engages with seven times more patients – an impressive feat considering patients who engage with the CipherOutreach calls have a 27% decreased likelihood of readmission compared to those who did not engage in the call. The program is proving effective not only in improving outcomes, but also in increasing patient satisfaction. 85% of Chase Brexton patients indicate that the calls are helpful in managing their care at home after a hospital or ER visit.

PATIENT ENGAGEMENT ANALYSIS

CLIENT: Chase Brexton Health Care, PROFILE: Maryland-based Federally Qualified Health Center (FQHC), PRODUCT: Post-Discharge Follow Up, PROGRAM: Readmissions Reduction, DATA PERIOD: Feb 2017-July 2017