"Our goal is to develop practical approaches towards the elimination of health disparities," said Amy Kind, MD, PhD, associate professor, Geriatrics and Gerontology. She gazed out at more than 10,000 staff members at Epic Systems while giving an All-Staff Meeting presentation on February 19, 2018, having been invited by the Electronic Health Records (EHR) industry giant to present her research on social determinants of care.

Working with large groups of people is an everyday event for Dr. Kind, but normally it involves analyzing massive datasets of healthcare information to test hypotheses about how factors such as living in a low-income neighborhood or having irregular access to safe housing, clean water, electricity, and connections with friends and family can affect one's health. Instead, her visit to Epic Systems involved direct interactions with thousands of software engineers, implementation professionals, analysts, and other EHR professionals.

Opening with a story, Dr. Kind described a case study of a 78-year-old patient with mild dementia and diabetes who was admitted to the hospital for pneumonia. Prior to discharge with a prescription for 7 day's worth of antibiotics, the patient was counseled intensively about the importance of filling his prescription and taking his medication. His caregiver, however, could not be present for the instructions; she had to work two jobs to make ends meet. Due to neighborhood safety concerns, home health services refused to follow up with him at his residence. Three days later, the patient was re-admitted. His prescription was still in his pocket, forgotten.

"Rehospitalization is a big problem. It affects 1 in 5 hospitalized Medicare patients, costs more than $30 billion per year, is the target of hospital-based Medicare penalties—and where you live matters because your neighborhood signals socioeconomic burdens affecting your ability to heal and recover," said Dr. Kind. "In terms of rehospitalization risk, living in a disadvantaged neighborhood is equivalent to having emphysema."

To illustrate the types of practical interventions that can help, Dr. Kind described the Coordinated-Transitional Care (C-TraC) Program that she launched in 2010 at William S. Middleton Memorial Veterans Hospital. C-TraC is a low-cost, primarily telephone-based, protocol-driven transitional care program carried out by a nurse case manager. An analysis published in 2012 showed that it reduced 30-day rehospitalizations by one-third, leading to significant cost savings while being well-received by veterans enrolled in the program.

The program has since been implemented in a variety of settings: at University Hospital, the VA hospital in Boston, several rural hospitals Colorado and others. Despite the challenges unique to each of these divergent locations, C-TraC has maintained a track record of reducing rehospitalizations, improving outcomes, and cutting costs.

Dr. Kind also described her work on refining and increasing accessibility to the Area Deprivation Index (ADI), a metric which allows neighborhoods to be ranked by socioeconomic disadvantage based on 17 US census indicators such as level of education, housing costs, unemployment rates, income levels, and housing quality markers-including factors like crowding. ADI is now being used for many purposes to target healthcare interventions such as diabetes programs to the areas that need them most.

Epic Systems members found the talk to be thought-provoking. "Dr. Kind's presentation resonated with Epic staff and offered a practical way to engage healthcare organizations in transitional care management. The work of reducing readmissions, especially in vulnerable communities, is incredibly important and integrated, which means many of us had actionable takeaways from the talk," said Claire Peterson, Implementation Services team.

And with that inspiration, perhaps, will come novel EHR-driven approaches that will help lower hospital readmissions and facilitate better health for large populations of patients.

Editor's Note: Dr. Kind's talk was the last of three invited presentations by Department of Medicine faculty members to Epic Systems employees during the 2017-18 academic year.

Resources:

• "Dr. Amy Kind launches new UW Department of Medicine Health Services Research Program," Department of Medicine, April 20, 2017
• "Dr. Vincent Cryns presents on UW-Madison Cancer and Obesity Research to more than 7,500 employees at Epic," Department of Medicine, October 19, 2017
• "Dr. David Andes speaks to audience of thousands about antimicrobial drug discovery writ large," Department of Medicine, February 22, 2018