Innovative program doubles patient engagement, cuts heart failure readmission rate in half

A San Diego medical group's disease management program increased patient engagement rates from 28% to 67%, leading to a decline in both hospitalizations and 30-day readmissions for program participants. In recognition of its innovative chronic care program, Sharp Rees-Stealy Medical Centers received the 2013 Doyle Award from MCG (formerly Milliman Care Guidelines), a leading provider of clinical guidelines to payor and provider markets.

"Together, the patient and care team create a shared action plan that is communicated to every caregiver along the way, driving patient-centered decision making," said Sharp Rees-Stealy's Director of Population Health Janet Appel. "Patients don't have to repeat themselves, and they don't feel lost in the system. Instead they have become engaged as their own best caregivers."

Sharp Rees-Stealy implemented a heart failure disease management program based on the MCG Chronic Care guidelines, creating a multidisciplinary team that works with patients to develop evidence-based plans of care. Transitioning from a fragmented process to coordinated care has enabled staff to identify candidates for the heart failure program early in their hospitalization, provide personalized attention, and move them seamlessly across the continuum of care. This has led to higher rates of patient engagement, as well as higher patient, physician, and nurse satisfaction levels.

The ultimate impact has been an overall 49% drop in 30-day heart failure readmission rates for Sharp Rees-Stealy HMO patients discharged with a primary or secondary diagnosis of heart failure.

"Chronic disease is the leading cause of death and disability in the U.S. and accounts for roughly three quarters of healthcare spending," said MCG President Jon Shreve. "Solving the puzzle of effective chronic care is the key to creating a sustainable modern healthcare system.  To do so, we need organizations with the boldness to innovate and the discipline to apply the best evidence – organizations like Sharp Rees-Stealy."