Transition Team Reduces Readmissions

Intervention Title:
Building a Care Transitions Team to Reduce Readmissions

Develop a patient care delivery model to support and facilitate a smooth, coordinated transition from one level of service to another, with particular initial focus on reduction of readmissions for heart failure patients.

St. Agnes Hospital’s all cause 30-day readmission rate following heart failure hospitalization dropped by nearly 13 percent over an 18-month period from 20.9 percent to 8.6 percent.

St. Agnes Hospital
Member of Agnesian Healthcare
430 East Division Street
Fond du Lac, WI 54935

St. Agnes Hospital is a 188-bed inpatient and outpatient acute care facility.  It is a member of Agnesian Healthcare, an integrated healthcare system that offers a complete continuum of services including three hospitals, long term care, home care and hospice, medical clinic network, reference laboratory and home medical durable equipment and oxygen services.  Serves a population of 100,000 in southeastern Wisconsin.

Barb Knutzen
VP Performance Excellence
P: (920) 926-5407

Innovation Implementation:
Poor transitions from the hospital to the home or other health care settings are a significant factor in avoidable patient readmissions. St. Agnes Hospital in Wisconsin recognized that combating this issue would require a new approach that used a dedicated team to support the care transitions rather than making minor process changes with existing staff.

The hospital and health system allocated more than $300,000 (an ongoing annual expense) to create the Agnesian Care Transition team.  The team consists of a director who analyzes readmissions data, determines trends and opportunities for intervention and makes recommendations to hospital department heads for improvement; and five registered nurses who act as care navigators by following up with patients post-discharge. The nurses span across multiple hospital units, including cardiology, oncology, palliative care, orthopedics and the emergency department. Chief among their responsibilities is to follow-up with all patients discharged within five days and ensure they understand their treatment plans, have made follow up appointments, and assess whether further support services are needed such as home care.

The Agnesian Care Transitions is a complete redesign of the hospital’s care processes and workflow; hospital administrators feel the monetary investment will pay off in cost savings and continued reductions in avoidable readmissions over time. In the first 18 months of the program, 30-day readmission rates dropped by 13 percent. Patient satisfaction scores (HCAHPS) have improved: overall quality from 66 to 75, discharge instructions from 84 to 87, communication with nurses from 74 to 80.