Reeves Memorial Medical Center's Chronic Disease Program Decreases Readmissions

May 2013
National Rural Health Resource Center (The Center)

Reeves Memorial Medical Center (RMMC) is a 15-bed Critical Access Hospital (CAH) located in Bernice, LA. In December 2011, Mary Guyot, Stroudwater and Associates, began working with the hospital leadership team to develop a one-year pilot chronic disease project focused on improving patient care processes in an effort to decrease unnecessary admissions and readmissions and ultimately decrease long-term cost of care. The project team chose to focus on addressing diabetes first. Landon Tooke, CEO, shared the following information with RHPI concerning the progress of this project.

Q: Why did you choose to focus on chronic disease for your RHPI project?

A: We have a good understanding of the Accountable Care Act and believe that hospitals, including CAHs and their clinics, would do well to initiate programs to improve care and decrease costs. Developing a chronic disease management program is one way that RMMC is supporting the federal program of Partnership for Patients: Better Care, Lower Costs with the intent to improve the quality, safety, and affordability of health care for all.

Q: What is your hospital's current status with regard to implementing the recommendations made during this project?

A: We saw a need in chronic disease, especially diabetes and ended up building a diabetic clinic. We are looking at the willingness of patients to engage in the program and the response has been tremendous. The clinic is completely booked and we can't even take new patients. In the past, they (patients) were only coming when they had issues and had varying degrees of stability. Through ongoing education and awareness, there has been a reduction in ER visits and admissions. The disease is more controlled and patients feel they are more in control and that disease is not "controlling their life." Patients are transitioning from being reactive about their disease to becoming more proactive. When we ask patients what has made the difference, they say they feel less intimidated and that people are taking the time to give attention to them.

Q: What were the expected outcomes of this project? Has your hospital been able to document any of these outcomes?

A: We don't have specific numbers yet, but none of the patients in the pilot program have been admitted or readmitted to the hospital.

Q: What are the expected next steps towards adopting your consultant's recommendations? Is there a sustainability plan?

A: We looked at data tracking and patient specific information but found it wouldn't be time or cost effective. As a result, we decided to use a software program that will work with the EMR for our clinics so that all data can transfer back and forth.  We hope someday to have a patient portal they can access; not just when they need acute care. We are planning to use social media to reach out too so we can reach them daily for reminders. We plan to do cardiac care as the next chronic disease using this model.

Q: Is there anything your hospital would do differently if you were able to repeat this experience?

A: The only thing we would do differently is to identify and integrate disease management software up front.

Q: Aside from the measurable outcomes, what has been the impact of this project on your community?

A: Patients going from reactive to proactive and are feeling more valued. The hospital is becoming a "health coach" rather than just a healthcare provider.  We are gaining tremendous knowledge about our patients which leads to better decision making. The relationships that are being developed will lead to long-term stability and loyalty towards the hospital because of the increased trust our patients have for us.