As Atlanta’s preeminent safety net hospital, Grady Memorial Hospital (Grady) is an essential resource for many who would otherwise have little to no access to medical services. In a bold move, hospital leadership looked to incorporate Jvion’s leading prescriptive analytics for preventable care solution—the Jvion Machine—with the system’s innovative Mobile Integrated Health (MIH) program to better serve patients and deliver personalized care. The results are delivering a 500% return while lowering the risk of readmissions, redefining the Grady experience, and putting the patient and his/her individualized needs first.
Founded in 1890, Grady is part of Atlanta’s bedrock. The system is the area’s preeminent “safety-net” hospital and the area’s only Level 1 Trauma center. It serves some of the most vulnerable and in-need patients in metro Atlanta.
Over a year ago, Grady leadership took an innovative and leading edge approach to lowering rates of patient illness and complications: combine the system’s leading MIH program with the prescriptive analytics power of the Jvion Machine.
A Brief Overview of Grady’s Prescriptive Analytics Solution
The Jvion Machine is built using an Eigenspace platform—an approach that is a proven asset in solving complex challenges such as quantum mechanics, search and consumer behavior, facial recognition, and now patient deterioration. This Eigen-based approach enables a comprehensive patient view that is amplified beyond the risk of an event to the clinical actions that will improve outcomes and drive patient engagement. Included within the intelligence of the machine are the socioeconomic factors such as literacy, income, access to transportation, and proximity to a food desert that drive more than half a patient’s risk. The key is that without the Eigenspace approach, all of this data is less meaningful and less effective at finding at-risk patients and pointing clinicians to the actions that will improve patient outcomes.
Combining MIH and Prescriptive Analytics for Preventable Harm
Grady’s MIH group delivers frontline, community based treatment for vulnerable patients at risk of returning to the hospital. Comprising teams of two that include one paramedic and one nurse practitioner, MIH members go directly to the homes of patients recently discharged from the hospital to ensure that they have the care and access to resources that they need to heal and stay healthy. It is a truly personalized approach focused on filling the individualized gaps that put a patient at risk. This could be as simple as making a follow up appointment to providing on-site medication and treatment. The MIH embodies Grady’s focus on delivering personalized care that improves health and the patient experience.
A Ride Along with Grady MIH
The Jvion Machine is used by the MIH group to prioritize patient visits; identify the clinical, behavioral, and socioeconomic factors contributing to the risk of a re-hospitalization; and to identify the actions that will best reduce risk while ensuring patient engagement.
This is a glimpse into the lives that the MIH group impacts and the outcomes they improve:
9:47 AM — the MIH team arrives at the first stop: a middle-aged man who frequents the hospital. The Jvion Machine flagged education and medication support as possible interventions. Through the course of the visit, the MIH team finds out the man is illiterate. They immediately call the pharmacy and re-order prescriptions with picture labels.
11:23 AM — a 50-year-old man is flagged at-risk by the Jvion Machine because of uncontrolled blood insulin. The team arrives and finds out that the patient hasn’t been to a physician in more than five years. They make an appointment with the Grady Diabetes Clinic and fill an over-the-counter prescription for insulin pens.
1:12 PM — the team arrives at the home of an 85-year-old woman flagged at risk of a readmission for pneumonia. The MIH team finds out that the patient has been bed ridden and ill for two days. The team immediately performs labs and x-rays on site, and confirms the outputs of the Jvion Machine. A prescription is filled, a follow up appointment is made, and transportation is scheduled.
Any of these events could have been fatal. By combining commitment, prescriptive analytics for preventable harm, and care, Grady’s MIH team is preventing avoidable, potentially deadly events from happening and improving the health of some of Atlanta’s most in need and most underserved community members.
Within a year, Grady has seen a 10% decrease in readmissions for the population targeted by MIH and the Jvion Machine. Not only was the immediate risk of a hospitalization decreased, the actions taken resulted in a lasting impact that decreased the risk of future hospital admissions. And the program is helping to lower the cost of care.
Across 2016-2017, Grady saved almost $700,000 in direct costs and realized a greater than 500% return on the program. And this was realized even with limited adoption of the solution. Going forward, Grady plans to expand the program to serve more patients with the individualized, personal care that is keeping Atlantans healthier and out of the hospital.