Lincoln County Medical Center, Ruidoso, New Mexico

Lincoln County Medical Center (LCMC), located in Ruidoso, New Mexico, was one of only four critical access hospitals (CAH) that earned national recognition for demonstrating innovative care coordination initiatives to improve population health.

LCMC has a data-driven project that has dramatically reduced hospital readmissions among Medicare patients. The hospital identified a need to reduce admission rates through their review of regulatory and health improvement organization literature on readmissions, their strategic goals, readmission data, and risk stratification. As part of the project, teams took a deep dive into the drivers of high utilization and adjusted programs to better serve patients.

One of the primary approaches to improving care coordination and reducing hospital readmissions was increasing the presence of case management in the emergency department (ED). Case managers regularly meet with the patients and their families in the ED to take a holistic approach as to why they are in the hospital or perhaps have returned to the hospital. The hospital also implemented a new patient and family questionnaire that was given to patients who have been in the hospital multiple times throughout the year. This questionnaire was modified to gain a better perspective of why the patient and his/her family members believed they were back in the hospital. The third major approach to support care coordination and reduce hospital readmissions was the implementation of home visits by emergency medical services (EMS). The hospital developed a process for EMS to visit the patients once they transitioned home.

Positive Outcomes

• The hospital's readmission rate for patients 65 years & older began at 6.5 percent in 2017, which did not meet their organizational goal of 5.2 percent. Through the approaches identified above, the hospital has reduced readmissions to 1.3 percent.
• As a result of the project, LCMC was also named a Quest for Excellence Award winner and Top Hospital for 2019 by the New Mexico Hospital Association.

Top Accomplishments

Increasing the number of case managers in the ED provided an opportunity for them to facilitate interventions or set up services that will support the patient such as home health services or outpatient counseling. Utilizing the patient and family questionnaire helped the clinical team gain an entirely new perspective on the various reasons for a particular hospital readmission. It also aided in facilitating the proper interventions and services that were put into place at the time of discharge. Finally, implementing EMS home visits helped facilitate communication and coordination with the patient and their families to ensure they had the resources and support they needed to be safe and healthy at home.

“I am incredibly proud of our team for their work on this project,” said Todd Oberheu, hospital chief executive. “With this project, they used data to take a close look at the reasons some patients ended up returning to the hospital and took important steps to address them. This is a great example of LCMC’s focus on improving the health of our community.”