At-risk patient ranking created

GREENFIELD — Hancock Regional Hospital is ranking its Medicare patients from lowest to highest risk and working to connect its most critically ill patients with preventive care programs aimed at preventing hospital stays.

Twelve percent of Medicare patients are responsible for 43 percent of costs, said hospital CEO Steve Long; these patients often suffer from one or more chronic diseases and spend lots of time in the hospital treating their illnesses, many of which are preventable.

Once the hospital has finalized the patient rankings, medical personnel can prioritize making contact more regularly with patients who face the most serious health concerns. Once those patients leave the hospital, they’ll receive frequent phone calls from health care providers who will check in on them, verify their medication schedule and make sure they have follow-up care planned.

Categorizing these patients’ needs is part of the hospital’s move toward more proactive care, not only treating people who come into the hospital but increasing efforts to prevent patients from needing to set foot inside its doors.

Ultimately, the hospital hopes to become a certified Patient Centered Medical Home, a new medical model created by the Agency for Healthcare Research and Quality that aims to transform the way primary medical care is organized and delivered.

“We wrap the patient in a variety of services that are focused on prevention and treatment of their chronic condition,” Long said. “This includes lab tests, imaging and following through on a plan of care their physician has for them, in a much more intimate and intentional way than we have before.”

The hospital’s efforts focus on following up with patients after they leave the hospital, helping them overcome obstacles to getting follow-up care — such as transportation — and encouraging them to take control of their health by eating healthy and exercising.

Preventing Hancock County residents from getting chronic diseases will save money and improve the overall health of the population, Long said.

Categorizing patients will help health care providers identify those patients who could benefit from more personalized attention.

“Once you can put your arms around what is contributing to their chronic illness, you can tailor a plan that works toward wellness,” said Louisa Hayenga, operations director for Hancock Physician Network.

The hospital’s community care team has three aims: to empower its patients, to increase access to treatment options and to deliver care in a cost-effective manner, she said.

Long-term patients who have chronic illnesses are assigned to a community care coordinator, who works intensively with the patient to make sure they have everything they need to be well, whether it’s answers to questions about recovery or transportation to follow-up appointments.

After a patient on Medicare visits a Hancock Physicians Network office, they are scheduled for a follow-up appointment, and the community care team makes sure they are taking the right medications in the right amounts. They also work to answer any questions the patient might have.

Patients make smarter choices about their health care when they are familiar with services available to them after a hospital stay.

“We are seeing less loyalty to the emergency room as the first line of care,” Hayenga said. “They now understand there are other, better opportunities to be seen.”

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Rorye Hatcher is a reporter at the Greenfield Daily Reporter. She can be reached at ​317-477-3211 or