The Rocky Mount Family Medical Center (RMFMC) in Rocky Mount, N.C., is seeing great results on readmission rates thanks to NC*Notify, a service of the N.C. Health Information Exchange Authority (NC HIEA).
The facility reported readmission rates for the last quarter at 9.2%, well below the average readmission rate for Medicare patients, which averages 17.8% nationally according to a 2024 study on reducing hospital readmissions.
NC*Notify is the event notification service of NC HealthConnex that provides near real-time admission, discharge and transfer (ADT) alerts on patients providers choose to monitor. This helps health care providers know when their patient has received care at a facility outside of their EHR (electronic health record) network.
NC*Notify alerts providers when their patient has visited an Emergency Department, allowing them to follow up with the patient in a timely manner and reduce readmission rates.
Emergency room staff usually have to rely on a patient’s memory or ability to tell them who their primary care physician is. If one is not listed or the patient cannot disclose that information, the hospital has no way of notifying that provider, who in turn has no way of knowing to schedule a follow-up visit.
The benefit of NC*Notify is that it lets doctors choose which patients to upload to monitor for external or transitional care events. RMFMC monitors all patients at their facility, allowing them to follow up quickly with any patient visiting the ED or discharged from the hospital. In Rocky Mount, these ED and hospital visits may take place at UNC Nash Hospital, which compiled data on their readmission rates shown in the chart below.
The chart shows the readmission rates of patients of area facilities to which UNC Nash sends alerts. These rates are compared to the national average of all payers of 14.6%. RMFMC is represented by the blue line, showing a reduction in readmissions to 9.2%.
“Besides cost reduction, this reduces patient suffering from having to go back to the hospital for avoidable events,” said Dr. Siu Tong, CEO of Cary Medical Management, which operates RMFMC. “This is another external data validation where NC HealthConnex made a significant difference.”
Dr. Tong credits this success to not only the ability to download their own patients’ ADT data from NC*Notify but also their ability to pull more clinical data from NC HealthConnex, the state-designated health information exchange. Using the NC HealthConnex Clinical Portal, clinicians at any of Cary Medical Management’s facilities can see a more complete picture of their patients’ health with clinical records beyond the discharge information from the hospital.
CMM also manages 47 other clinics with a patient population of 40,000 through commercial and government value-based care contracts. In 2023, CMM showed similar success with NC*Notify by maintaining an 8.3% readmission rate. That same year, the average cost of readmissions was $16,000, according to a meta-analysis on 30-day readmissions and hospital quality performance. For the Rocky Mount clinic patients who were admitted at Nash Hospital, Dr. Tong estimates that CMM has saved around $1 million annually for their Medicare Transitional Care Management patients by using NC*Notify and the NC HealthConnex Clinical Portal.
The NC HIEA is excited to see another practice leveraging our data exchange tools and value-added services to great success. These services are free of charge to those facilities with a Full Participation Agreement. If you would like more information on signing up, please visit our website or reach out at hiea@nc.gov.