Five Hospitals' Approaches
Learn how five programs aim to reduce potentially avoidable hospitalizations through better care transitions.
Our fragmented health care system fails to coordinate patients' care among different doctors' offices and hospitals. Without that coordination, patients discharged from hospitals don't get support and encouragement to take their pills, follow their diets, show up for follow-up appointments, or otherwise follow the regimens that doctors have prescribed during their hospitals stays. Poor care coordination contributes to the revolving door syndrome at America's hospitals in the name of readmissions.
- Preventable readmissions cost Medicare about $12 billion a year.
- Rehospitalization is a frequent, costly, and sometimes life-threatening event that is associated with gaps in follow-up care.
- Three-fourths of chronically ill patients who leave the hospital wouldn't need a return trip if they had a plan for follow-up care.
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Newton-Wellesley Hospital implemented a variety of initiatives focused on improving its discharge process. Two critical components of the project included streamlining its data collection and enhancing communication between hospital staff.
Methodist South Hospital formed a multidisciplinary in-hospital team to develop interventions targeted at reducing the hospital’s readmissions rate.
Medina hospital created a readmissions database and set up a new workflow process to target heart failure patients with education to avoid a readmission to the hospital. Over 18 months, readmissions were reduced by 9 percent.
Oregon Health and Science University cut readmissions for heart failure patients by 11 percent over an 18-month period through improved patient education.
Since implementing a Care Advocate position, Marymount Hospital has steadily maintained 100 percent compliance with core measures for heart failure care and reduced its heart failure readmission rate by 26 percent.
Responding to newly emerging models of coordinated care, staff at University of Utah Health Care piloted hiring a transitions navigator, leveraging best practices from national care transitions leaders.
Queen of the Valley Medical Center uses the CARE Network to ensure a seamless continuum of care from hospital discharge back into the community setting is established.
Northern Piedmont Community Care implemented a nurse care manager program, which utilizes home visits with patients recently discharged from the hospital to make sure that a care plan is established and followed.
Mercy Health in Cincinnati, Ohio implemented Dr. Eric Coleman’s care transitions model by using nurses specially trained to act as patients’ guides through the discharge process.
Seeking to reduce 30 day readmissions rates, Cullman Regional Medical Center sought to improve communication and patient understanding at the point of discharge.