Managing chronic conditions like congestive heart failure (CHF) is challenging for any health system, but in rural areas with limited resources, it’s even more complicated.
Magnolia Regional Health Center in northeast Mississippi is a municipally owned, 200-bed hospital that cares for a largely underserved population. Faced with high readmission rates and medication access barriers among its CHF patient population, the health system took a closer look at how they could support patients after discharge. In a recent webinar, Ben Long, M.D., Director of Hospital Medicine at Magnolia Regional, joined Colin Banas, M.D., M.H.A., and Weston Blakeslee, PhD, of DrFirst to share how the community hospital integrated digital solutions in its MEDITECH electronic health record (EHR) system to improve medication adherence and reduce readmissions within 30 days of discharge.
Magnolia Regional operates outside the reach of any dominant health system. Dr. Long explained, “We care for a sick and underserved population. The challenges we face are characteristic of what the broader healthcare system struggles with as a whole—social disparities, fragmented care, and regulatory complexity.”
The hospital may be small, but its goals are bold. As Dr. Long put it, “We weren’t achieving the outcomes we wanted, so we got serious about looking at the data and identifying gaps we could address—starting with heart failure patients.”
The Magnolia team created a scorecard to track not only readmissions but also prescribing behavior and adherence patterns. “The idea was to be very intentional about identifying patients and understanding what was actually happening after discharge,” said Dr. Long. “We knew medications played a major role in preventing readmissions, so we started there.”
The scorecard allowed the care team to monitor whether patients had been prescribed guideline-directed medical therapies (GDMT) and whether they were filling them. With those insights, the team turned to DrFirst for help addressing key barriers to adherence: affordability, education, and follow-through.
“One of the biggest problems doctors have when writing a prescription is understanding if it’s covered,” said Dr. Banas. “What’s it going to cost? Does it need a prior auth? Are there alternatives that cost less? Should it be sent elsewhere? Is it eligible for mail order? Unfortunately, a lot of times [doctors are] flying blind.”
With the real-time price transparency tool from DrFirst integrated into the hospital’s MEDITECH EHR, providers can see what a prescription will cost a patient based on their actual benefit plan and the pharmacy selected—before hitting “send.”
As Dr. Banas explained, “This isn’t an estimate. The system sends a representative claim to the pharmacy benefit manager, which lets the prescriber see how much the medication will cost based on the patient’s plan, where they’re at with their deductible, and which pharmacy they’re using. If the patient met their deductible that morning, the system knows that when the doctor sees the patient in the afternoon.”
Dr. Long added, “As we were exploring the price transparency tool, I was shocked by the large price discrepancies between different pharmacies. Our patient population is part of a very tight knit community, and many patients go to independent pharmacies rather than the larger chains because of their relationship with the pharmacist, which could span decades. It’s important that our providers can engage with patients about the different options that affect out-of-pocket costs.”
Magnolia also implemented the DrFirst patient engagement solution, which delivers personalized messages via SMS to a patient’s mobile device within minutes of a prescription being written. Messages include prescription details, educational content, cost information, and financial savings opportunities. Patients can even schedule a reminder to pick up the medication at the pharmacy.
Dr. Banas explained why timing matters: “You only get so many chances to nudge a patient. A lot of drop-off happens because life gets in the way. This solution helps fill that gap at the exact right moment.”
The results were telling. In a cohort of patients with CHF who received these messages, those who engaged had 19% higher odds of filling their prescription—and 6% lower odds of being readmitted to the hospital within 30 days. “This is real-world proof that small nudges can drive measurable outcomes,” said Dr. Blakeslee.
Magnolia didn’t stop with digital engagement. They also equipped nurses with real-time prescription fill data from DrFirst as part of a nurse navigator program to help promote adherence.
“The nurse navigator reviewed each patient’s med list, identified any gaps in guideline-directed therapy, and followed up after discharge,” Dr. Long explained. “They could see if the patient filled their meds and intervene early if they did not.”
This hands-on approach paid off. A nine-month study of 171 patients showed that 8.9% of patients filled all four of the categories of GDMT. After the nurse navigator intervention, that jumped to 14.5%. That’s a significant increase, as the clinical literature shows that only about 6% of patients are filling all four medications in the GDMT pillars.
“This isn’t an academic medical center doing this,” Dr. Long emphasized. “This was a regular team with engaged providers and smart IT support. If we can do it, others can too.”
Magnolia’s story shows that with the right combination of data, technology, and personal connection, small hospitals can drive big improvements in outcomes for high-risk patients.
Want to hear the full conversation and see the results? Watch the webinar on demand.