When the mother of a leader at Ochsner Health was discharged from one of the system’s hospitals, orders for her follow-up appointments were placed in her medical record, but the plan wasn’t clearly explained to the patient.
“She was discharged with implied instruction to set up her own appointments,” said Beau Raymond, MD, chief medical officer for population health at Ochsner Health, a nonprofit system based in New Orleans. “She didn’t know what she was supposed to do.”
Dr. Raymond recognized from that experience that Ochsner must proactively make sure patients being discharged are consulted about the appointments they need and ensure it is at a time when they are able to complete those visits.
“We needed to be smarter about simple care coordination activities,” Dr. Raymond said during his presentation at the 2026 AMA Insight Network Summit in Chicago.
That coordination has become central to Ochsner Health’s strategy to reduce hospital readmissions and emergency room visits by providing a suite of acute home care programs. Dr. Raymond calls home-based care during the initial discharge from the hospital the single most effective method of lowering readmission rates for those at high risk—but he stressed the importance of coordination.
“We built great programs, but in silos, that didn’t necessarily talk to each other,” he said. “So, we've connected them to make sure they're actually helping with those transitions.”
Ochsner Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
“Opportunities to do better"
The system’s home programs emphasize the first 15 days after hospital discharge, which Dr. Raymond says is the period of highest risk for patients returning to the hospital.
“Most readmissions come from that first 15 days,” he said. “So we realized that in order to reduce readmissions, we need to offer care in the home, outside of the clinic walls.”
“We're really trying to see how we can take care of patients in that transition period —that’s a period where there are certainly lots of opportunities to improve,” Dr. Raymond added.
These efforts include four integrated initiatives:
- An acute care at home program includes in-home visits with registered nurses, the first within a day after discharge; diagnostics; IV therapy and medication titration; phone calls and remote monitoring.
- A nurse practitioner (NP) at home program similarly provides NP visits for medical management as needed, typically up to 90 days from hospital discharge, and care for homebound patients.
- Ochsner Health’s transitions of care programs include a transitional care clinic, patient navigator outreach by text message after a patient’s ER visit, a post-hospital discharge text messaging program and a nurse triage hotline for escalating home health care.
- Dedicated outpatient care managers identify and address unmet needs in high-risk, complex care patients and assist with appointments and medications.
Dr. Raymond said these programs have saved thousands of bed days, reduced readmissions and ER visits, and saved thousands of dollars per patient. These initiatives also enable Ochsner Health to keep some emergency patients from needing hospital admission. Patients get the added benefit of getting home sooner, knowing they’ll receive the care they still need.
Managing congestive heart failure at home
In particular, Ochsner Health has focused on providing these services for patients with congestive heart failure, which are at high risk for readmission. The system has implemented a process to identify patients at risk and establish them with Ochsner Health’s home-based care programs.
In the first 15 days after discharge, patients will receive daily monitoring and home interventions as needed, such as IV diuresis and medication adjustment. If a patient’s monitoring indicates that an escalation in care is needed, paramedics will be called to provide an assessment, and the program will provide pathways to physician care.
After 15 days, the patients transition to the NP at home program and for follow-up that may include cardiology and primary care physicians. After 90 days, they’ll move on to the outpatient care management program, which may include assistance by community health workers or social workers and interventions to address social drivers of health.
They also have virtual visits from primary care physicians and specialists for patients who can’t come to a doctor’s office regularly.
“They're actually managing patients outside the clinic, in the home, on a routine basis for extended periods of time,” Dr. Raymond observed. “You need to have that handoff.”
Each level of the program is designed to support the next one, as patients progress from acute stabilization to transitional engagement to sustained longitudinal management.
“By doing all those things, then it's additive, and more impactful than episodic patient care,” Dr. Raymond said.
“Make it easy for people”
Ochsner Health had 293 patients with congestive heart failure in 2025 enrolled in the acute care at home program. This accounted for 15% of the program’s home patients and 16% of all reutilizations. Improving these patients’ care coordination is the focus of the system’s strategic priorities for congestive heart failure care in 2026.
Those priorities include expanding emergency department identification, automating workflows in Epic, standardizing reporting to create a single source of accurate data, and creating sustainable return on investment modeling.
“Differences in these patients’ health insurance coverage add a challenge to coordinating their care. Some payers won’t cover the acute care at home program,” Dr. Raymond said. “If they can’t go to the acute care at home program, then we want them to go to the NP at home program so somebody’s seeing them.”
The variations in patients’ medical needs and coverage make it a challenge for case managers, who can’t know every payer rule and eligibility pathway. Ochsner Health is putting processes in place to make it easier for case managers to choose programs and make referrals.
“The case managers located in the hospital need insight into programs available to the patients in their area—all of the options—and make it easy to know the best one,” Dr. Raymond observed. “We need to make it easy for people. And so that's what we're working on.”
Getting beyond silos and slivers
The lessons of Ochsner Health’s acute home care programs, of course, apply to most other kinds of health care programs as well. They may succeed on their own, but they’ll likely work better if they’re integrated with related programs. That integration requires health systems to develop programs’ referral, health record, communication and accountability structures that connect with each other.
“We all build programs, we can prove that they work, we can do ROIs, et cetera. But we need to be able to say how we get one to talk to the next,” Dr. Raymond concluded. “Otherwise, we're helping this sliver and this sliver and this sliver. They all live in silos. We need to get coordinated across the board.”
Learn more with the AMA about value-based care, including resources to help ease participation for physicians and their practices.
