Focus on Care Coordination – Improving Patient Outcomes, Reducing ER Visits & Hospital Readmissions

The Methodist Physician Group (MPG) is a hospital-based organization with locations in three counties in Western Kentucky. MPG is comprised of acute and ambulatory services that include various multi-specialties. They see nearly 10,000 patients per month at 18 clinics, plus a same day clinic.

Sue Ginn, RN, is the Quality Improvement Specialist and Analyst, and heads their Quality Improvement team. The team members are comprised of clinical, IT, and administrative staff. Team members include: Amy Scales, Tiffany Smith, Jenny Phillips, Chanda Smock, Christy Stone, Scott Lutz, Janet Burnett, and Todd Duckworth. Vance Drakeford of Kentucky REC serves as the Quality Improvement Advisor for the practice. They have concentrated their efforts on building a Quality Improvement team and engaging clinicians and staff in quality improvement activities. This has been the intervention responsible for much of their success. MPG brings value to their patients through improved outcomes, care coordination, patient experience, and reduction of costs associated with care. This driving force places Methodist Physician Group in a position to be highly successful in various value-based payment models.

Performance Area Highlights

Beginning in November 2015, a pilot Care Coordination role was added to the MPG team at one of their primary care locations, and soon after another location was added to their responsibility. The goal for the Care Coordination role was to help reduce risk of readmissions, ER visits and facilitate follow-up care with patients’ primary care providers. This has led patients to improved understanding of their conditions, comorbidities, treatment and health goals.

Their high level of care coordination has resulted in a decrease of their 30 day Hospital Readmissions, showing a 0.80% improvement from 2017 to 2018. Specific patient populations have seen even higher reductions in the 30 day Hospital Readmission rates: Acute Myocardial Infarction = 1.5%, and COPD = 4.50%. Total Knee and Hip Arthroplasty had a 2% increase; however, they were 1% below the Expected All Cause Readmit rate. This is a 1.2% improvement on being below the Expected All Cause Readmit rate from 2017.

Additionally, their care coordination has led to a reduction in ER visits from 2017 to 2018. ER visit reduction has led to an estimated cost savings of $983,180.00 based off adjustment of total patient population, and CMS’s average cost of $902.00 per ER visit.

These reductions are credited to MPGs dedication to comprehensive, patient-centered care that has proven to decrease hospital readmissions and ER visits.

The MPG Care Coordinators review the daily hospital and ER discharge lists, and then call discharged patients to discuss the following:

    • Check on their current conditions
    • Confirm follow-up appointments
    • Verify appropriate medication has been received
    • Verify medication education understood


These actions have proven to be the most effective factors for the 30 day hospital readmission reduction and decreased number of ER visits.

Key Success Factors

Not only has the team seen reductions in 30 day hospital readmissions and ER visits, but the staff has gained satisfaction in the “little things” by helping patients with such things as: transportation assistance to appointments; diagnosis education; self-management with their diagnoses; coordination with various local agencies; and coordination with case management companies for other medical referrals to ensure patients receive the best care available.

MPG has added a total of five Care Coordination roles to their team since they began in late 2015 due to the success of this effort. These roles now include Medicare Gap and Medicare Wellness Appointments. This has helped improve the health of their patients, and helped catch abnormalities early by encouraging patients to have preventive screenings completed. Their work has not only helped keep patients out of the hospital, but it has also integrated an entire patient focus, improving the overall wellness of and care for their community and patient population.

We asked members of the MPG team questions regarding their experience with practice transformation. Here are some of their answers.

What’s the #1 thing you’ve gotten from your four years of practice transformation work?

Sue answered, “After the first conference I came back thinking ‘OMG what have I gotten into, it’s the tiger by the tail and the tiger has me!’ With the help of KYREC, it was still hairy scary, with a lot of work, but less intimidating because we could go to (Kentucky REC Quality Advisors) Vance, Robin, and Kelly for help.”

“I knew cost was always important, but thought of it in regard to patient affordability until working with KYREC. Now I understand the impact of cost on the healthcare organization, and the payers.”

How did you choose to focus on care transitions, particularly your hospital readmission rates?

Sue answered, “In 2015 the hospital was taking a hit with 30 day readmission rates, it’s bad for the bottom line and staying in the black. We had a restructuring in MPG – to add a care coordinator under a trial basis; we saw the advantage of it with just a couple providers, decided to move forward with other practices. We had a high number of readmits and avoidables at the beginning. Then we hired a care coordinator, and it just turned into more.”

“It was definitely worth it! The goal for the nurses is the outcome of the patient. The administration is looking at the financial bottom line, for us patient care is absolutely #1. We see clinical outcomes. With these changes, all sides benefit.”

“We saw the benefit it would make to our patients and in the community. Healthier patients, better community!”

Contact our Quality Improvement Advisors at Kentucky REC for all your quality improvement questions. We’re here to help: 859-323-3090.