Quality Improvment 2012: Improving Transitions of Care
Project Goal: Reduce 30-day Readmission Rate from an average of 11% to an average of 8% or less.
Time Frame: May 2009 - present
Project Summary: Hospital readmission is a national issue. Nearly 20% of Medicare patients in the U.S. are readmitted within 30 days and the cost associated with hospital readmission is over $17 billion in 2004 (15% of total Medicare payments for hospitalization). In addition to the financial burden of readmission, it is distressing to patients and families. Research has identified evidence-based best practices that health care settings across the continuum of care can implement to reduce hospital readmissions. As such, SVHC developed an “Improving Transitions of Care” team comprised of staff from its rehabilitation and long-term care facility, the hospital, physician offices and Visiting Nurses Association to implement best practices shown to decrease hospital readmissions. When the project started, SVMC had a readmission rate that was between 12% and 10%. The goal of the “Improving Transitions of Care” team was 8% with a stretch goal of 6%.
SVMC joined a national initiative called Project BOOST – Better Outcomes for Older Adults for Safe Transitions (A national program mentored by the Society of Hospital Medicine). The Project BOOST best practices implemented at SVMC to improve patient care transitions have included:
- Implementation of a “teach back” technique to gauge patient understanding of information communicated to them
- Post-discharge appointments scheduled prior to discharge
- Post-discharge follow-up calls made next business day after discharge
- Implementation of pull systems in the medical home to follow-up with patients after hospitalization or ED visit
- Implementation of electronic physician discharge orders that incorporates recommendations from all disciplines involved in patient’s care and treatment
- Development and implementation of standardized discharge packet
- Daily Team Huddles where case managers, pharmacists, long-term care staff, visiting nurse association representatives and social workers identify and address a patient’s risk factors for readmission during the hospital stay
As a result of these and other interventions, SVMC’s readmission rate had dropped to 9% by August 2011. The Transitions of Care Team will continue to work on this important project until we see sustained improvement of 8% or less.
Contact: Jennifer Fels, RN