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Case Study: Determiningthe Clinical
Efficacyof Homeward Health’s Digital
Discharge Program
Introduction
The Homeward Health™ team wanted to
revolutionize the discharge process by creating
an integrated system of education, prioritization
of resources, and communication. Their Digital
Discharge™ platform was developed to help
patientsstay out of the hospital anddecreasethe
number of Potentially Avoidable Readmissions
(PAR) hospitals receive annually. The locale
chosen for the ten-month pilot, was the
Progressive Care Unit (PCU) within Hurley
Medical Center and began September 29, 2014.
This unit is centered on caring for heart-failure
patients and normally incurs many readmissions,
approximately 67 per month. The unit was
selected for the reasonable number of beds
present and its focus on treating Congestive
Heart Failure (CHF) patients, a diagnosis with a
high readmission rate (25.1%) [1].
Many different methods have been used to try
to decreasethenumber of PAR hospitalsacquire.
Recently, introducing monetary penalties has
been used to reduce hospital readmission rates;
the measure was started in 2012 by the Centers
for Medicare and Medicaid Services (CMS) [2].
CMS developed the so called Readmission
Reduction Program which fines hospitals with
excessive 30-day readmissions. This adds an
additional incentive to keep PAR rates low.
Many hospitals have since attempted to determine the best methods of decreasing PAR. A 2013
report published by the Robert Wood Johnson Foundation (RWJF) gave light to some of the
problems facing the modern healthcare system, appropriately named “The Revolving Door.” The
study took a look at quantitative readmission data, as well as qualitative testimony from Medicare
patients to identify common themes which patients and caregivers felt increased patients’ risks of
PAR [3]. Despite increasing penalties and many attempts by clinicians to decrease readmission
Setting: Hurley Medical Center, Flint MI,
2014-2015
Purpose: Reduce potentially avoidable
readmissions
Pilot
Duration: 10 months
Preliminary Results: Promising; up to 47%
reduction in readmissions
Technology: Homeward Health’s Digital
Discharge™ Platform on a mobile
workstation
Oversight: Institutional Review Board, Team
Meetings
Contributors
Jim Glassbrook, Data Analyst at Hurley
Medical Center
Mico Malecki, Chief Information Officer for
Homeward Health
Renee Link, Director of Data Analytics at
Hurley Medical Center
Zach Beavers, Researcher & Whitepaper
Author at Hurley Medical Center

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rates, the result of the RWJF study showed little to no improvement nationally for 30-day
readmission rates over the study period of 2004-2010, regardless of the cause of the index
hospitalization[3].Italsoshowed a commonthemeof problemsatdischargeincreasingPAR rates
[3].
In order to curb the problems identified in the RWJF study, such as a lack of individualized
attention, patient comprehension/retention difficulties, poor instruction quality, inadequate
transitionof care,and lackof support structures athome, HomewardHealth™setcorrectingthese
complaints as some of the primary goals of their product.
The pilot is the first of its kind at Hurley Medical Center. The Digital Discharge™ program is ideally
given to each patient within a day of admission to one of PCU beds. A staff member enters the
patient’s demographic information for contact and tracking purposes. Also entered into the
program are the presence or lack of advanced care directives and any heart failure, diabetes
mellitus, COPD, pneumonia, and total joint replacement diagnoses [4]. The program is then
administered to the patient on an iPad®
-equipped mobile workstation.
Within the program, the patient is exposed to care information and then questioned (true/false
and multiple choice) which gives visual and auditory feedback. Based on the patient’s ongoing
answers, the content is tailored in real time to what would be most beneficial to the patient. The
content was selected by Homeward Health™ basedon current medical literature and practices, is
written and spoken in a manner that allows sixth-grade-reading-level comprehension, and is
aimed at providing patients with a triple-sensory (touch, sight, and sound) approach to learning
which has been shown to aid in retention [5].
The adaptive software learnsfromthe patientwhile also gainingvaluableinsightinto the patient’s
health and improving health literacy. The information gained from the patient is used by the
program to alter the content to better fit the patient’s educational needs. Additionally, certain
“trigger” questions will automatically send an alert to nurses and case managers. An example of
this feature includes contacting case managers if the patient desires to be discharged with home
care or an appointment with a new primary care physician.
One of the program’s other main goals is to better allocate staff resources. Although staff
members often realize which patients need more individualized time to discuss their care plans
and health, these realizations are not always transferred from staff member to staff member
during shift changes. When the new staff member, be that a case manager, nurse, therapist, etc.,
begins working, he will have to again determine how his time will be partitioned among his
patients. The Digital Discharge™ framework establishes a Risk Score™ for the patient to become
a PAR within 30 days. The model can be used to accurately gauge where particular healthcare
team members’ time is best spent and which issues need to be covered more in depth.
This score is a hybrid algorithm, partly based on a quantitative, scoring method of predicting PAR,
and partly based on the patient’s answers to psycho-social questions posed to him based on six
Risk Score categories:

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1. Support System
2. State of Mind
3. Medication Management
4. Diet and Physical Activity
5. Lifestyle
6. Warning Signs
In a study of potentially avoidable 30-day hospital readmissions published by Dr. Donzé et al.,
8.5% of the discharges from the three hospitals studied in the Partners of HealthCare network
were calculated (using the SQLape algorithm) to have a PAR within 30 days of an index discharge.
Dr. Donzéusedmultivariate,logarithmicregressiononthedatasettocreatea model foraccurately
predicting how likely a patient was to be readmitted within 30 days [6]. The prediction score, now
known as the HOSPITAL model, is based only on quantitative data and does not utilize any
predictors based on socio-economic factors, education level, mental status, or the
presence/absence of support systems. This is why a hybrid system, based on the HOSPITAL score,
was chosen by Homeward Health™ to better predict whether a patient has the health literacy,
compliance, and support, as well as the quantitative predictors, to avoid being a PAR within 30
days.
Clinical Pilot
Inclusion Criteria
The pilotincludesindexadmissions fromSeptember30th
,2014 through July 31st
, 2015 with
surveys during that admission or surveys greater than 30 days prior to discharge. It
includes readmissions for patients who were discharged and readmitted through August
31st
, 2015. As hospital encounters involving CHF are frequently flippedfrom admissions to
observations, and vice-versa, the several months after the pilot serve as a buffer to ensure
most cases have been decided one or the other. Patients seen on the PCU during the
previous year (prior to the pilot’s start), served to establish a baseline for comparison.
Exclusion Criteria
In order to eliminate as many extraneous variables as possible, some data needed to be
excluded. Exclusion criteria included: expired patients, same day readmissions (second
admission was treated as a continuation of the first), observation patients,
elective/outpatient admissions, and patients who were discharged with a planned
readmission. Patients who were transferred to acute care facilities, psych, rehab, and
hospice care were also excluded.
Methods
The Digital Discharge™ program was preloadedon a hospital approved iPad®
attached to
a mobile workstation that could be brought into each patient’s room and used at the
bedside. It was attempted to reach every patient in the PCU with the program early on in
his/her admission. For the pilot only, the nursing staff were not regular providers of the

4. 4
program to patients; instead, an independent contractor compensated by Homeward
Health™ broughttheprograminto eachpatientroomto providea moreconsistentservice.
Data was collected by the contractor and all quantitative health data was taken from the
Hurley EMR in an IRB-approved, retrospective research project.
Patients’ risk of PAR was estimated by using six different subscores for evaluating
psychosocial wellbeing combinedwith the already proven HOSPITAL model. The adaptive
algorithm aims to stratify how likely patients are to be readmitted on a scale of 1-5, five
being a high risk.
Results and discussion
Readmissions
Of the 948 patients discharged from the PCU during the 10 month pilot program (11
months of counting readmissions), 324 underwent the survey. These patients represents
34.2% of the 948 patients in the unit.
The baseline, all-cause readmission rates for the PCU were calculated to be:
 27% for an index CHF admission
 14.3% for a cardiac index admission (without CHF)
 20% for a cardiac index admission (with CHF included)
An initial one month trial of the pilot appeared promising, showing a modest decrease in
readmissions. However, the ten-month pilot showed more pronounced reductions. The
post-pilot, all-cause readmission rates are shown below:
 14% for an index CHF admission
 13.7% for a cardiac index admission (without CHF)
 13.9% for a cardiac index admission (with CHF included)
The similarly described readmission rates above were compared, and there was a
remarkabledecreaseinreadmissionsfortwoof the three categories.Thepilot’smainfocus
was on CHF patients and saw a 47% reduction during the pilot as compared with the
previous year’s baseline for CHF patients. The reduction in readmission rate for patients
with CHF admissions exceeded expectations and may be partially inflated by
uncontrollable parameters, such as not every patient receiving the program. However, the
following control helps account for several of these sources of error during analysis.
Patients with cardiac index admissions but without CHF who were given the program
showed only a slightdecreasein readmissions (approximately4.2%).BecauseCHF showed
a significant decrease in readmissions while those that the program’s content did not
specifically address lacked a significant drop in readmissions, it seems that the program’s
content has a positive effect on readmission rates for those patients that the content is
relevant for. When patients were grouped into a general cardiac diagnosis sample, the

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group had an all-cause readmission rate reduction of 33.4%, relative to the PCU baseline,
showing that even when looking at the cardiac patients in the unit as a whole, the effect
on readmissions is significant.
The results above translate to 69 fewer 30-day readmissions per one-thousand patients.
This puts patients who are normally frequent readmissions into a more appropriatepath
for good patient care.
Handling Super Utilizers
One problem commonly being faced by the healthcare industry is so called, “super
utilizers.” These are a small number of patients that consume a relatively large proportion
of healthcare resources. As illustrated in Figure 1, 5% of the population utilized 49% of
total medical expenditures [7]. In order to minimize the amount of in-patient resources
these patients utilize, Hurley opened a special outpatient resource specifically for these
types of patients with the goal of managing their care without utilizing the emergency
department or patient “floors.”
This aptly named Complex Care Clinic is open two days a week and is capable of serving
100 patients. It is staffed by Hurley employees with a focus on leveraging community
assets to managemental healthand healthliteracy [8].During its firstyear, it reducednon-
emergentemergencydepartmentvisits by 78% and createdan estimated$334,287in cost
savings despite being only at 32% capacity [9].
Homeward Health™ analyzed the electronic medical records (EMR) of the complex care
clinic’s patients and found that their predictive algorithm was able to correctly spot all of
the patients as super utilizers with a high risk for readmission [8]. Homeward Health™ is
applying this algorithm to currently admitted patients who may be potential candidates
for recommendation to the Complex Care Clinic. In the next pilot, these recommendations
will hopefully be integrated into case managers’ and physicians’ discharge workflows.
Figure 1. An illustration of different percentages of the population and the associated
percentage of the national healthcare cost [7].
22%
49%
64%
80%
97%
3%
≥$35,543
≥$11,487
≥$6,444
≥3,219
≥$664
<$664
0%
20%
40%
60%
80%
100%
Top 1% Top 5% Top 10% Top 20% Top 50% Bottom 50%
Percentoftotalcosts(%)
Percent of Population (%)
Concentration of HealthcareCosts for 2002

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Satisfaction
A patientand staff satisfactionsurvey was conductedby HomewardHealth™ todetermine
how well theprogramwasreceivedbythose involved. Of the 132 patientsthat participated
in the satisfaction survey, 100% of them were, “satisfied with the digital discharge process
and believed it to be a superior experience to traditional instruction [8].” The exact
breakdown of the scores is illustrated below in Figure 2:
Figure 2. An illustration of patient satisfaction scores. A rating of five represents extreme
satisfaction while a rating of zero represents extreme dissatisfaction.
Similarly, the staff satisfaction survey had similar results (Figure 3). Of the 17 nurses who
were involvedin the process and surveyed, 100% of them weresatisfiedwiththe program.
In fact, 76.5% of the nurses rated the experience as highly satisfied or extremely satisfied.
Figure 3. An illustration of staff satisfaction scores. A rating of five represents extreme
satisfaction while a rating of zero represents extreme dissatisfaction.
115
12
5 0 0 0
0
20
40
60
80
100
120
Five Four Three Two One Zero
NumberofIndividuals
Satisfaction Rating
Patient Satisfaction Scores
5
8
4
0 0 0
0
1
2
3
4
5
6
7
8
9
10
Five Four Three Two One Zero
NumberofIndividuals
Satisfaction Rating
Staff Satisfaction Scores

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The scores frombothperspectivesappearveryfavorable. Inanenvironment that canmove
at a feverish pace at times, it is paramount that any product introduced, not only add to
the experience of patients, but also to those involved in administering it. Based on the
survey results, it seems that Homeward Health™ has succeeded in creating a product that
providesan improvedexperienceforthose involvedin the dischargeprocess, patientsand
staff alike.
Future Directions
The Homeward Health™ team has many avenues to direct their attention towards in the
future. Presently, the team is adding new modules to the Digital Discharge™ program,
including new cardiac catheterization and colonoscopy options [10].
Hurley is beginning initial integration procedures for their EMR, Epic, and staff will start
independentlyperforming“DigitalDischarges” inthe future [11]. In addition,there aretwo
additional programs that will be added in a follow-up pilot with Hurley, the Risk Score™
and Care Trans™ packages. These platforms will hopefully form an integrative care system
that will add to existing strategies by Hurley to keep patients from “falling through the
cracks” and being readmitted (see Figure 4 below):
Figure 4. A visual representation of the implementation of Digital Discharge™, Care
Trans™, and the Risk Score™ technologies.
While the implemented Digital Discharge™ program actively categorizes patients on their
risk for readmission, it does not make these notifications available for staff by itself. Its
primary purpose is to educate the patient on several modules of their health, which can
lead to decreased readmission rates. The Risk Score™ functionality adds onto the patient
education and risk stratification side of the Digital Discharge™ program by distributing
scores to wherethey’re neededmost, to nurses, casemanagers,and physicians. The scores
are provided in an intuitive dashboard interface. In the future, the Hurley EMR will provide

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links to this dashboard for those who should have access. It gives a listing of all of the
patients within the unit and even a breakdown of each patients’ composite risk scores into
categoriesthatcanbe focusedon in one-on-one,staff-patientinteractionsduringthestay.
The interactive staff dashboard allows for the final package, CareTrans™, to be used. This
packageis used to further mitigate readmissionsbyallowingtheattentionthat the patient
received while admitted to be continued once they are discharged. The CareTrans™
package uses automated SMS and telephone messages to be delivered to patients at
home, reminding them of doctors’ appointments, taking medications, and other activities.
In addition, CareTrans™ also links patients to outside resources like the Hurley Complex
Care Clinic and telehealth™ psychiatric appointments. These resources are not currently
readily accessible to patients, and this platform leverages assets normally unknown to the
patient to create a more accessible health support and maintenance structure.
The Digital Discharge™ program been one of many new technologies Hurley Medical
Center has investigated. It has been shown to be an effective tool to decrease
readmissions, at least in the scopes of the pilot study, by educating patients. It can also be
a useful management utility to determine which other tools patients would benefit from.
Continued study with larger patient volumes and other diagnoses will be valuable in
further validating the results of this product and evaluating its ability to differentiate
between what tools need to be subsequently implemented for better patient outcomes
after discharge.
Conclusions
Although there needs to be further testing to improve the statistical power of the data,
some conclusions can be drawn:
 The system is easily integrated into existing clinical workflows.
 The Digital Discharge®
programeffectively improves hospital readmission rates
by reducing the number of potentially avoidable readmissions.
 The algorithm is based on existing studies and can successfully determine high-
risk, super-utilizing patient populations.
 Both patients and staff were satisfied with the product, and find it provides an
improved educational experience, as comparedwith traditional patient
instruction.
References
[1] M. Qasim and R. M. Andrews, "Statistical Brief #142: Post-Surgical Readmissions among
Patients Living in the Poorest Communities," Agency for Healthcare Research and Quality,
2009.

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[2] A. Elixhauser and C. Steiner, "Statistical Brief #153: Readmissions to U.S. Hospitals by
diagnosis, 2010," Agency for Healthcare Research and Quality, 2013.
[3] Dartmouth Atlas Project; PerryUndem Research & Communications, "The Revolving Door:
A Report on U.S. Hospital Readmissions," Robert Wood Johnson Foundation, 2013.
[4] J. Gough, Interviewee, President & CEO Homeward Health, LLC. [Interview]. 10 November
2015.
[5] R. Kim, A. Seitz and L. Shams, "Benefits of Stimulus congruency for Multisensory Facilitation
of Visual Learning," PLoS one, vol. 3, no. 1, 2008.
[6] J. Donze, D. Aujesky, D. Williams and J. Schnipper, "Potentially Avoidable30-Day Hospital
Readmissions in Medical Patients Derivation and Validation of a Prediction Model," JAMA
Internal Med., vol. 173, no. 8, pp. 632-638, 2013.
[7] L. J. Conwell and J. W. Cohen, "Characteristics of Persons with High Medical Expenditures in
the U.S. Civilian Noninstitutionalized Population, 2002. Statistical Brief #73," Agency for
Healthcare Research and Quality, Rockville, MD, 2005.
[8] SG-2, LLC, Homeward Health's Analytics at Hurley Medical Center.
[9] Michigan Association of Health Plans, "Taking services into homes, using data to target
high use individuals, boosting immunizations among 2014 MAHP Pinnacle Award winners,"
17 September 2014. [Online]. Available:
http://www.mahp.org/sites/default/files/MAHP%20issues%20Pinnacle%20awards.pdf.
[Accessed 30 June 2015].
[10] J. Gough, Interviewee, President & CEO Homeward Health, LLC. [Interview]. 20 April 2015.
[11] M. Roebuck, Interviewee, Chief Medical Information Officer Hurley Medical Center.
[Interview]. 20 April 2013.