During Phase 1, Emory Healthcare, Grady Health System, WellStar Health System, and Kaiser Permanente will launch a coordinated data collection phase. There is also the potential for Piedmont Healthcare to participate in Phase 1 as well. There are an estimated 6,000 heart failure patients with an inpatient stays across these systems, and having them launch at the same time will allow for robust data collection for the baseline analysis. Data collection will include the measures outlined in the ICHOMS dataset, but will also include information about heart failure stage and other demographic measures.
Alongside data collection, hospital systems will begin implementation of the Coleman Transitions model, an evidence-based intervention designed to lower readmissions, on select patients. These patients will be selected based on rigorous risk analysis, which will be standardized across the hospital systems.
A payment model, currently under negotiation, will fund the intervention during the first two years of implementation and reward systems that achieve the pilot’s shared outcomes and goals.