Dover, Del.-based Bayhealth is cutting heart failure readmissions by 67 percent through a pilot program that focuses on social determinants of health.
The pilot program uses a CMS-recommended screening questionnaire, the answers from which are then plugged into its EHR, according to an Oct. 25 article on the American Medical Association website. Unite Delaware, a third-party community organization partner, then connects patients to resources such as food, transportation and more.
"That's what we hope contributed to some of that decrease in readmissions. Folks were able to get to their follow-up appointment with their cardiologist, because now they had that transportation or maybe they would get some healthier food with a lower salt content," John Fink, MD, Bayhealth vice president for quality and medical affairs, said in the article.