Health IT

Health system streamlines diabetes care to reduce readmission rate

Pam Shannon

What does diabetes have to do with readmission rates?

More than the administrators, doctors, nurses and educators at TriHealth thought.

Pam Shannon, a nurse and vice president of population management at TriHealth, said that everyone was surprised at the analysis of the readmission rates of people living with diabetes.


“With each condition — pneumonia, AMI, heart failure — people with diabetes were more likely to be readmitted to the hospital than people who don’t have it,” she said.

TriHealth’s chief medical officer gave Shannon a challenge: Reduce the percentage of readmit for those individuals with diabetes and the three targeted conditions.

To understand the current state of TriHealth’s diabetes education, Shannon said that she talked with patients and employees throughout the Cincinnati health system. It includes two acute care hospitals and more than 80 locations. The result of all these conversations was a video parody of the disconnected system and conflicting messages patients were getting.

“We had a summit in mid-November to launch our new council and we had to laugh at ourselves a little bit to get the conversation going,” Shannon said.

Shannon said that each time a patient discussed diabetes with a different person in TriHealth — a parish nurse, a pharmacist, a doctor — she got a slightly different set of instructions.

“The variations in the system were creating a confused and noncompliant patient,” Shannon said.

The goal of the council is to develop a basic set of treatment plans that can be adjusted to fit an individual. With a standard approach, everyone at TriHealth working with diabetes patients will send the same message.

“No matter where you go within system, we recognize the patient’s point in the system.” she said. “If a patient is on plan A, pharmacists, educators and doctors would all know about that plan.”

TriHealth uses EPIC across the board, so the plans could be stored in a patient’s EHR at some point.

TriHealth also has a relatively new dashboard that includes a comprehensive data set of diabetes metrics from the level of an individual patient to all the patients in one doctor’s practice to all the patients in TriHealth’s system.

Shannon said that this new way of turning data into improvements in patient care is the power in a health system.

“We have people who know lots about diabetes, we just have to step back and include the patient on share decision-making,” she said.

In addition to the new diabetes working group, TriHealth is launching a family advisory council that will advise TriHealth leadership, physicians and staff regarding their feedback and expectations for an improved patient-centered experience.