Advisory
Coordinating Better Outcomes
Focusing on patient education and collaboration with physicians and the hospital, Gundersen Lutheran's care coordination program has achieved remarkable results. The program has not only improved patient outcomes but also reduced health care costs. The 325-bed health system, based in La Crosse, Wis., and serving counties in Iowa, Minnesota and Wisconsin, enrolls the sickest 1 to 2 percent of its patients as long as they meet the program's criteria. Criteria include frequent hospitalizations, multiple chronic conditions and lack of home support, but the ability to pay is not a prerequisite. RNs and social workers serve as care coordinators, working with each patient to increase compliance with medication and treatment plans, help manage social and emotional needs and prevent hospital readmission. From 2009–2011, for 373 patients, length of stay decreased 39 percent at 12 months and 46 percent cumulatively at 24 months, and total charges decreased by 39 percent at 12 months and 60 percent cumulatively at 24 months. Unplanned readmissions declined 51 percent at 12 months and 64 percent cumulatively at 24 months. Gundersen Lutheran plans to expand its care coordination program to include moderately sick patients who also would benefit from these services. For more information, contact Beth Smith-Houskamp, executive director, patient- and family-centered care, at esmithho@gundluth.org.
Focusing on patient education and collaboration with physicians and the hospital, Gundersen Lutheran's care coordination program has achieved remarkable results. The program has not only improved patient outcomes but also reduced health care costs. The 325-bed health system, based in La Crosse, Wis., and serving counties in Iowa, Minnesota and Wisconsin, enrolls the sickest 1 to 2 percent of its patients as long as they meet the program's criteria. Criteria include frequent hospitalizations, multiple chronic conditions and lack of home support, but the ability to pay is not a prerequisite. RNs and social workers serve as care coordinators, working with each patient to increase compliance with medication and treatment plans, help manage social and emotional needs and prevent hospital readmission. From 2009–2011, for 373 patients, length of stay decreased 39 percent at 12 months and 46 percent cumulatively at 24 months, and total charges decreased by 39 percent at 12 months and 60 percent cumulatively at 24 months. Unplanned readmissions declined 51 percent at 12 months and 64 percent cumulatively at 24 months. Gundersen Lutheran plans to expand its care coordination program to include moderately sick patients who also would benefit from these services. For more information, contact Beth Smith-Houskamp, executive director, patient- and family-centered care, at esmithho@gundluth.org.
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