Tracking Patient Progress Through Personalized Data Reports

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Tracking progress on key hospital readmission metrics and comparing data from other state and regional providers is providing the TMF Quality Innovation Network (QIN) team with important perspective. The insights, they say, are helping to improve health care quality and promote goals.

The Centers for Medicare & Medicaid Services QIN-Quality Improvement Organization (QIO) is providing 30-day readmissions reports on a quarterly basis to all acute care hospitals (both recruited and non-recruited) in its region, as well as all post-acute care providers in recruited communities. 

TMF QIN began creating the reports in 2011, working with providers in Texas, and in 2014 expanded its work to include its entire region of Arkansas, Missouri, Oklahoma, Texas and the U.S. territory of Puerto Rico. This extension highlighted the need to develop provider-specific data reports, with benchmark data, for all entities participating in the project, including Prospective Payment System hospitals, nursing homes, home health agencies and inpatient psychiatric hospitals. It was imperative that all providers measured 30-day readmissions using the same methodology: Medicare fee-for-service claims. 

Once TMF QIN generates the reports, staff members notify providers via email and through one-on-one communication. Providers can then access the reports, including their facility-specific data along with aggregate community- and state-level data, through a members-only data portal on the TMF QIN website. The QIN-QIO’s health care quality improvement specialists teach providers how to understand and use the data in the reports to implement better processes in their facilities.

The reports offer a unique perspective into the trends of the Medicare population, which help identify interventions, gaps and the need for process change. 

Case Study: Guadalupe Regional Medical Center

Guadalupe Regional Medical Center (GRMC) in Seguin, Texas consistently reviews the TMF QIN’s quarterly reports and comparative data, according to Rhonda Unruh, the medical center’s vice president for quality. The reports validate GRMC’s own internal readmissions data and show how GRMC compares to other providers.

GRMC went a step further, using its readmissions data to guide efforts on patient populations that are frequently readmitted to see how the medical center could improve. Unruh said unit directors interviewed readmitted patients and/​or their families and asked questions related to the discharge process. Was there anything patients and their families needed? Was there something they didn’t anticipate? Was the medical center not adequately preparing patients to return home? 

Reducing readmissions is an organizational goal for GRMC that the staff work on continuously, Unruh said. GRMC has incorporated discussions on reducing readmissions into various huddles and efforts at all levels of the organization. 

Unruh said GRMC has been able to reduce its readmission rate because of the processes it has put in place over the past several years. We have used our data to help us improve internal processes that can impact whether a patient is readmitted,” she said.

Additionally, GRMC uses the QIN-QIO’s patient-facing zone tools, and staff attend care coordination community coalition meetings that the TMF QIN help facilitate. GRMC also partners with the TMF QIN on other focus areas such as promoting diabetes self-management education and improving chronic kidney disease treatment through screening and education. 

For more information about the TMF QIN data portal and provider reports, email readmissions@​tmf.​org