Case Studies
OVERCOMING HEALTH INEQUITIES
Grady Health System: Overcoming Health Inequities in Historically Marginalized Populations
Grady Health System, a safety net hospital, used innovated approaches and multidisciplinary care to identify and manage social determinants of health (SDOH) and reduce disparities in care for vulnerable populations with heart failure (HF).
Grady Health System wanted to improve quality care and outcomes in historically marginalized populations with HF who are vulnerable to poor outcomes.
The Grady Heart Failure Program (GHFP) was created to provide inpatient and outpatient coordinated systems of care, including:
- Multidisciplinary care from advanced practice providers, cardiologists, a community health worker, a nurse care coordinator, a pharmacist, and quality/process improvement personnel
- Inpatient interventions, including routine SDOH screeners in the EHR, appropriate patient education, and referrals
- Outpatient interventions, such as a 30-day supply of HF medications, financial assistance, community connections to resources, appointment rideshares, medically tailored meals, remote blood pressure and weight monitoring, and mobile home health visits
The GHFP reduced readmission rates and had high rates of post-discharge patient contact and scheduled follow-up visits.
- 6.4% reduction in 30-day all-cause readmission rates
- 30-day HF-related readmission rate of 10.7%
- 94.3% of patients were contacted by phone within 3 days of hospital discharge
- 97% of patients scheduled follow-up visits within 7 to 14 days post discharge