Population Health: A topic sponsored by Vree Health

Vree Health is dedicated to developing technology-enabled services designed to help: Coordinate care across providers; Aggregate and utilize disparate data sources; and Better engage patients and families in their healthcare.

Health system streamlines diabetes care to reduce readmission rate

10:48 am by | 2 Comments

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.

Copyright 2015 MedCity News. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Veronica Combs

By Veronica Combs

I was the editor in chief at MedCityNews.com. I started writing and editing in the print world and joined a dotcom right before the 2000 crash. I was at TechRepublic/CNET/BNET for 7 years. Health was more interesting to me than the latest version of Windows, so I left for a startup tracking prescription drug news. A year later, MedTrackAlert was acquired by HealthCentral, so I shifted to audience research. The fun of daily news and interviewing smart people brought me to MedCity News in February 2012.
Visit website | More posts by Author


Healthcare is facing major challenges and Vree Health wants to help you balance the business and financial burdens while inspiring patients to become more active in their care. Aimed ultimately at helping improve the effectiveness of provider care plans and patient outcomes, Vree Health provides customized technology-enabled services for patients, family caregivers, hospitals and healthcare providers. Learn more at VreeHealth.com