2. About Memorial Not-for-profit community hospital Level 2 Trauma Center
3000 +Employees; 300+ physicians
412 Beds; 80+ clinics
16K Admissions annually
22K Surgical Cases annually
414K OP visits annually
70K ED Visits annually

3. Strategic Priorities Population Health Engagement / Care Coordination
Physician Alignment
Clinical Improvement
Clinical and Financial Analytics
Customer (Patient) Satisfaction
Supports all priorities

4. Care Coordination Programs
Community Health Initiative (CHI)
Health Catalyst/Outpatient Navigator
Preventative
Chronic Care Management (CCM)
- MD Revolution/Outpatient Navigator
- 20 Minutes Billable Non-Face-to-Face
Transition of Care Program
- Emmi Solutions/Case Manager

5. Challenges Care Transitions: Challenges IMPROVE CARE COORDINATION
$24-45B – National annual cost of poorly coordinated transitions
CHALLENGE: CONSISTENT, EFFECTIVE, COMMUNICATION
DRIVE SELF-MANAGEMENT
2x – Increase in readmits when patients lack knowledge & skills
CHALLENGE: INCREASE PATIENT COMPETENCE
AVOID & REDUCE READMISSION
$25B – Annual cost of preventable readmissions
CHALLENGE: IDENTIFY PATIENTS AT-RISK

7. Care Coordination Improvement
Meaningful Outreach
Contact Patients
Drive Self - Management
Understand Patient Status
Report Patients Potentially At-Risk
DO THIS FOR EVERY PATIENT

8. Emmi Emmi Transition Interactive call campaigns
Reinforces key messages with patients/caregivers
Tracks interactions and identifies risk factors
Corresponding Emmi Engage programs
Engages with Emmi’s soothing voice
Collects vital information from patient
Provides daily reports on patient status
Notifies staff of patients at potential risk

9. Emmi Emmi Transition Topic List General Discharge General Orthopedic
Two calls, three Emmi programs
Stroke
Five calls, two Emmi programs
Pneumonia
15 calls, three Emmi programs
Heart Failure
Acute Myocardial Infarction
15 calls, two Emmi programs
General Orthopedic
4 calls, one Emmi program
COPD
6 calls, two Emmi programs
Behavioral Health
9 calls first 3 weeks post-discharge
Breastfeeding
12 calls in 12 weeks post-discharge
Total Joint Replacement
10 calls in 90 days post-discharge

10. Emmi Memorial’s Successes 72% PATIENTS REACHED
82% PATIENTS REACHED INTERACTED ON MORE THAN HALF OF ALL CALLS
SURVEYED PATIENTS REPORTED
81% Stated they had an improved opinion of their provider
76% Stated they were better prepared to manage their health
69% Stated they were more comfortable calling their provider

11. Emmi Memorial’s Successes
“WE HAVE CASES OF IDENTIFYING ISSUES, THAT COULD HAVE QUICKLY BECOME LIFE THREATENTING, IF THEY HAD NOT BEEN ADDRESSED IN A TIMELY MANNER…DUE TO THE INTERCESSION OF THE EMMI PHONE CALLS AND THE INTERVENTION OF THE NURSE FOLLOWING UP ON RED AND YELLOW FLAGS…”
Will discuss specific cases

12. MHG Care Coordination
Readmission Case Manager

13. Medicare Readmission Reduction Program
FY % Penalty
FY % Penalty
FY % Penalty
FY % Penalty
Will discuss specific cases

14. Medicare Readmission Reduction Program
Pepper Report
Short-Term Acute Care PEPPER
30-day Readmissions to Same Hospital or Elsewhere
Memorial Hospital at Gulfport
Q1 = Oct-Dec Q2 = Jan-Mar Q3 = Apr-Jun Q4 = Jul-Sep Time Periods
Target Area Discharge Count (Numerator)
Denominator Count
Percent (Numerator/ Denominator)
Q1 FY 2014
253
1,350
18.7%
Q2 FY 2014
252
1,400
18.0%
Q3 FY 2014
294
1,395
21.1%
Q4 FY 2014
278
1,343
20.7%
Q1 FY 2015
266
1,352
19.7%
Q2 FY 2015
270
1,396
19.3%
Q3 FY 2015
267
1,393
19.2%
Q4 FY 2015
1,325
19.1%
Q1 FY 2016*ICD10
228
1,269
Q2 FY 2016
1,407
17.9%
Q3 FY 2016
246
1,388
17.7%
Q4 FY 2016
245
17.6%

15. Next Steps Additional Emmi Transition calls/programs
Stroke/CABG Readmission Reduction projects
Continued Care Coordination efforts in outpatient primary care
Involvement of community (post acute providers)

17. Questions