Follow-Up Visits Can Significantly Reduce Post-Discharge Mortality and Readmissions for Highest Risk Patients

NASHVILLE, Tenn., Oct. 31, 2024 /PRNewswire/ — Today at NCQA, a leading health quality innovation conference, Houston Methodist and Health Data Analytics Institute (HDAI) jointly discuss the impact of focusing follow-up appointments on patients at high risk.

HDAI’s analysis of both Houston Methodist’s patients and a national dataset of over 10M Medicare patients demonstrated the effectiveness of targeted follow-up appointments for reducing mortality and readmissions for the top quintile of patients at risk of readmission and 30-day mortality within the first 14 days after discharge.

The data showed a distinct inverse correlation – when 14-day follow-up rates for patients increase, those patients are less likely to die post-discharge or readmit. For patients seen later than 14-days post-discharge or who are at lower predicted risk, there is small to no effect on mortality and readmissions.

Stuart Dobbs, M.D., Chief Quality Officer at Houston Methodist Hospital, states, “What we learned is another reminder that what you don’t know, you can’t measure, and what is not measured, usually is not improved. We have some of the lowest inpatient mortality rates in the country. However, our post discharge mortality rates were about average compared to large academic medical centers. We are now focused on scheduling high risk patients with a follow-up visit (within 14 days or less) prior to their hospital discharge.”  

Brenda Campbell, RN, Senior Consultant Houston Methodist Health System Innovations, added, “Risk stratification tools can assist organizations in prioritizing care based on the unique needs of patients while managing limited resources.”

HDAI’s HealthVision intelligent health platform was embedded in Houston Methodist’s Electronic Health Record (EHR) so that clinicians on the floors and in specialty clinics could identify and schedule appointments for the most impactable, high-risk patients before discharge. In addition to using the risk-ranked rosters, the clinicians use the patient chart summary to quickly assess any specific risks and key drivers of health, summarized and updated in real-time, to facilitate personalized care planning.

“By leveraging real-time EHR integration of advanced predictive analytics and generative AI, clinicians on the floors are identifying high-risk patients along with granular underlying drivers of risk to help create targeted follow-up plans,” adds Nassib Chamoun, Founder and CEO of HDAI and a co-presenter at NCQA. “It’s not about seeing more patients, which is not feasible with scarce resources, but about focusing on the right patients while also reducing the administrative burden on clinicians. Our collaboration with Houston Methodist highlights the transformative potential of data-driven approaches in enhancing patient care and optimizing health outcomes.”

The program is expanding to all the Houston Methodist hospitals with focus on continuously improving the processes and technology necessary for consistently high rates of post-discharge follow-up programs for patients with the greatest need.

About Health Data Analytics Institute (HDAI)
HDAI, a HealthTech company, has created the first Intelligent Health Management System, HealthVision^™. Powered by predictive analytics and generative AI, HealthVision allows clinicians to work smarter, not harder, helping to fight clinician burnout, improve care coordination, and lower overall costs. For more information, please visit: www.hda-institute.com and on LinkedIn at linkedin.com/company/hdai.

Company contact: Carola Endicott, carola.endicott@hda-institute.com, 617-699-0725

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SOURCE Health Data Analytics Institute