Meet Jim, a 65-year-old male with COPD, a bladder condition, diabetes, financial barriers and food insecurity.
Jim, confined to a wheelchair, has no transportation, which makes it difficult for him to attend his physician appointments.
He is one of many living in Northern Nevada who go under the radar, challenged by environmental and social issues with little understanding of how to navigate the healthcare system.
What happens after Jim's hospitalization is key to his future, and for Jim the odds are against him.
Hospital readmission rates in Nevada
Hospital readmission rates are used to measure a hospital's quality of care. Returning to the hospital within 30-days is costly and often avoidable.
According to America's Health Rankings, Nevada is ranked 47th nationwide in hospital readmissions.
However, Northern Nevada healthcare leaders at Renown Health have implemented innovative solutions, with partners such as Innovative Healthcare Delivery (IHD), to deliver high-touch advocacy programs that assist patients during and post hospitalization to ensure they get the healthcare services they need and are set up for long term success.
What happens after hospitalization is key to a patient's future
Due to no transportation, Jim canceled his post-hospitalization urology appointment to remove his stent.
However, IHD's patient advocate intervened and coordinated no cost rides for doctor appointments, provided by the Regional Transportation Commission, to ensure Jim had resources to get the care he needs.
During a home visit, Jim mentioned he only had one shirt that fit him, due to weight loss he experienced during his hospitalization.
The next day, IHD returned with donated clothing items, in his size. IHD also identified the need of Personal Assistant Services to assist with bathing, since he was struggling due to his weakness.
It's been months since Jim's hospitalization, he has attended his much needed doctor appointments, has the care he needs at home and he has not returned to the hospital.
Reducing hospital readmissions increases economic savings
Beyond improving medical outcomes for Nevadans, access to appropriate clinical and community resources contribute to economic savings as well.
A recent independent study shows that the IHD program that supported Jim, reduced hospital readmissions by as much as 33%, according to a 2019 white paper authored by Jim Woodburn, MD, MS, one of the founders of the Blue Cross Association's National Medical Management forum and former leader at United Health Group/Optum Health.
Statistics show people like Jim are more likely to be readmitted to the hospital after an initial hospitalization.
The good news is that due to Northern Nevada healthcare leaders and their commitment to improving healthcare in our community, Jim has beat the odds.
Shelli Lara is Founder, President and CEO of Innovative Healthcare Delivery, a proven program for improving quality outcomes and reducing costs for health plans, hospitals, corporate employers and self-insured clients utilizing a high touch, patient centric non-clinical approach.