readmissions totaled $7 billion for four high-volume
conditions (acute myocardial infarction, congestive heart
failure, chronic obstructive pulmonary disease, and
pneumonia). 2 And of course, this is just the economic
impact—it’s hard to measure the pain, heartbreak, and
stress of a readmission to patients and their loved ones.
But when patients are actively engaged in their health on
an individual basis, remarkable things happen.
For example, consider Jerome O’Connor, a patient
recently discharged from a four-day hospitalization. On
the recommendation of his physician, Mr. O’Connor
enrolled in a patient engagement program designed to
ease his transition back home and prevent an avoidable
readmission. Each day, Mr. O’Connor called into the
program and answered a short series of questions measuring his clinical status, self-care activities, and social
determinants of health.
“I think when people get out of the hospital, they
tend to go back home and sink into their same old
habits, not thinking about it anymore,” Mr. O’Connor
said. “This program is valuable though, because I think
about my health more often now and what I can do to
improve it, such as eating better. Also, there was an RN
at my primary care provider’s office who was charged
with following up on my daily survey answers. Developing a relationship with her was important to me
because now I’ve got someone I can call and ask a question or two without having to make an appointment to
see the doctor. I really enjoy that resource.”
The New Normal
Self-reported data is powerful beyond the numbers
because risks to patients, such as dizziness as a measure of fall-risk or depression as a measure of general
decline, aren’t all easily quantifiable. What matters is
when a patient shares that they are more forgetful than
normal or dizzier than normal.
As important as it is to gather information from
patients, it is equally important to know what to do with
that information. Care managers can analyze and deliver
daily monitoring information in an exception-based
workflow. This means that the care manager only needs
to review patients who report meaningful changes or
are showing troubling trends. Patients generate an alert
when reporting a change in their condition, one that is
substantial enough to say “today isn’t normal.”
Take for instance the experience of James Merson.
Mr. Merson spent a brief stint in the hospital due to
pneumonia. “No matter what health issue I had in the
past, I used to just try to use over-the-counter drugs. I
can’t do that anymore because I have a compromised
immune system,” says Mr. Merson.
“The program got me thinking about my health and
the things I need to do to stay healthy. I’m starting to
be more aware of what’s going on with my body,” Mr.
Merson noted. “By answering the questions, the program has helped me know what to be aware of and what
to do. I think it saves a lot of people in bad shape from
Win-Win for Everyone
This kind of patient engagement model helps keep
patients healthy and happy and allows care managers
in group practices to manage caseloads efficiently.
Evidence shows3 that if a patient participates in an
engagement program like this for 30 days, it becomes a
part of their lives. Patient engagement like this increases
a patient’s accountability for his or her own health and
becomes a healthy habit. Healthy patients are happy
The outcomes speak for themselves:
■ ■ Compliance with keeping doctor’s appointments:
85% physician appointments kept
■ ■ Medication adherence because patients are asked
about it: 98% prescription fill rate
■ ■ Compliance among patients about managing their
chronic conditions (e.g., daily weighing, checking
blood glucoses daily, and monitoring their medications)
■ ■ 60% reduction in all-cause admissions
We don’t mean to, but in health care, all too often
we leave out the most important person—the patient.
Patients have a lot to say about their care and interac-
tions with their providers. They want to be engaged,
and if they see and feel the benefits, they’ll stay con-
nected, happy, and loyal to your practice.
1. X. Jiaquan, S.L. Murphy, K.D. Kochanek, and E. Arias. 2016.
Mortality in the United States, 2015. Data Brief No. 267,
National Center for Health Statistics. Accesssed June 1, 2017
2. K. Fingar and R. Washington. 2015. Trends in Hospital
Readmissions for Four High-Volume Conditions, 2009-2013.
Statistical Brief #196, Healthcare Cost and Utilization Project.
Agency for Healthcare Research and Quality. Accessed June
1, 2017 at hcup-us.ahrq.gov/reports/statbriefs/sb196-Read-
3. Pharos Innovations. Pharos analysis, Fairview Health Services, 2013–2014.
Jim Evans is executive vice president, business and
client development, Pharos Innovations; and Patrick
Herson, M.D., is president, Fairview Medical Group.