Innovation Challenge Award Winner: Advocate Good Shepherd – Barrington, Illinois

Proactive care planning is an integrated and innovative interdisciplinary designed care management approach that leads to reduced healthcare costs and readmission rates, while maximizing hospital reimbursement. ED over-utilization causes overcrowding, strains resources, and increases costs and wait times. Developing individual care plans (ICPs) in an emergency department (ED) produces solid partnerships with patients, health care providers, post-acute providers, and external agencies, and builds a community of support for the patient. The ICP program achieves successful quality outcomes by managing ED recidivism and unnecessary admissions, and is inclusive of the patient to optimize health and manage healthcare cost. The results at Good Shepherd are remarkable and evidence of a significant shift in patient care and improved outcomes. Since the program’s inception, over 800 ICPs have been created with a cost savings of over $4.9 million with 61% reduction in ED recidivism and 53% reduction in readmissions.

This program focuses on ED patients who have a high recidivism rate and/or incur a high rate of admissions. EDs do not tent to provide consistent care from visit to visit, and are cost prohibitive venues for the treatment of minor or chronic health conditions. The purpose of this project is to put control of the patient’s condition back in the patient’s hands by creating a degree of wellness that allows the person to function at their highest contributing level. The patient becomes an active member of the team and often a driver of the plan in conjunction with the people who know the patient best. By planning and creating options and choices, the plan is patient-driven and inclusive.

While spreading this intervention through the innovation challenge in 2018 we found there were some important characteristics which led to successful high impact implementation:

Must Have:

Ability to convene/re-dedicate existing team of ED nurse, ED physician, ED care manager, and ED manager/director/leader
Ability to modify EHR to “flag” patients with an ICP (within implantation time frame)
ED physician buy-in and support
Strong administrative/executive buy-in

Should Have:

Ability to mine data on current high-utilizers (e.g. a spread site must be able to identify the 10 most frequently visiting ED patients)
Ability to pull in ad hoc members to the care team

Could Have:

Social worker on care team
Chaplain on care team

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