Case Study: Visiting Nurses Association Realizes Fewer Readmissions with hb/notify Service


Imagine this: you’re a physician, and your 85-year old, Type II Diabetic (DM II) patient is admitted to the Emergency Department (ED) with hypoglycemic symptoms. She is triaged, ED protocols for management of acute hypoglycemia are employed to control her symptoms, and she is discharged home. Weeks pass, and your patient suffers another acute crisis related to her DM II and is transported to back to the ED. This is a familiar cycle for patients living with chronic diseases like DM; this patient will need multiple interventions to manage her disease successfully. What is missing from this scenario is an intervention that works to keep the patient asymptomatic and out of the ED.

Now, instead imagine a technology that alerts your staff the minute your patient is registered in the ED. It is a similar scenario, but the potential outcome is very different: your 85-year-old diabetic patient is rushed to the ED – confused and dizzy. You’re alerted by a real-time phone message that your patient has been admitted. You or another care coordinator meets your patient at her bedside in the ED. While your patient is still in triage, the care coordinator from your staff is working with the ED team to find more effective solutions. Your knowledge of the patient and her history informs decisions about her plan of care and plans for discharge. Your patient goes home as in the previous scenario, but this time home health services have been arranged.

The next day, your patient receives a visit from an RN with expertise in managing DM II. Post-visit you receive an update on the patient’s status. Over the next few weeks, you collaborate with the home health nurse, the patient, and her caregivers to find a plan that works. Trips to the ED and unnecessary hospital readmissions are avoided.

“Better use of time and resources toward more efficient care”

Vivian Hunnings RN

Vivian Hunnings RN

Vivian Hunnings, a Nurse Liaison, RN, and Chaplain with the Visiting Nurses Association (VNA), utilizes the hb/notify service from The Health Collaborative to benefit home health patients from the University of Cincinnati Medical Center (UCMC). The hb/notify service allows the VNA to submit a patient panel with basic demographics, and then receive secure alerts and notifications when one of their patients visits the ED at any participating hospital in the Greater Cincinnati area. VNA continues to receive alerts that track the patient’s progression through the ED, then hb/notify sends a final alert when the patient is discharged home or admitted to UCMC.

By using the hb/notify solution, provider organizations are able to provide better patient care while making themselves eligible to receive reimbursement for timely follow-up. hb/notify is particularly helpful to practices that are participating in CPC+ and other quality improvement programs that require transitional care and chronic care management.

For Vivian and the VNA, hb/notify means better use of time and resources towards more efficient care. “I’m alerted when the patient enters the ED. I continue to receive alerts with any change in care status via email and phone. The hb/notify alert is the starting point for connecting all points of care,” shares Vivian. “I’m able to collaborate with the UCMC ED team while talking to the patient at bedside. hb/notify allows us to get a patient to the right level of care – immediately.”

Real results – in real time
Notifications from hb/notify provide the VNA liaison with a way to collaborate with UCMC staff in real-time when critical decisions about patient care are made. “We are seeing fewer hospital readmissions, and decreases in the number of days a patient remains in the hospital, by using the alerts in this way,” says Vivian.

hb/notify alerts support a much better model of care for VNA patients. “In the past, because we don’t usually see our patients every day, there were times when we would be alerted by neighbors that a patient had been hospitalized,” Vivian shares. “With hb/notify I’m alerted right away. I’m coordinating care at the first encounter. It really is the difference between horse & buggy and driving a Tesla.”

Another benefit of hb/notify for organizations like the VNA is patient retention. When a patient is admitted, a hospital may refer to any number of post-acute care partners. With hb/notify, home health agencies can ensure that patients return to them, providing continuity of care. “If I can keep my patient out of the hospital and from being bounced around between care settings, then I’m providing quality care. At the end of the day, it really is about better care for patients,” says Vivian.

For more information about hb/notify and the hb/suite of health information exchange services, please contact Jason Buckner, SVP Informatics, at 513.247.6878 or

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