Hattiesburg Clinic is reducing hospitalization rates thanks to a predictive model they developed in conjunction with Epic. The model calculates a hospitalization risk score for patients with chronic conditions, helping Hattiesburg identify candidates for their chronic care management program. Participating patients get monthly MyChart messages or phone calls from CCM nurses, along with other services to help them manage their conditions.
As a result of the program, Hattiesburg saw:
- Twice as many patients enrolled in CCM in the first six weeks after program implementation.
- Improved clinical quality measures for patients with chronic kidney disease, cardiovascular disease, and diabetes.
- A 12% decrease in hospitalizations for patients enrolled in CCM.
Epic community members can read more here.