Implementing Change to Reduce Readmissions: A Team Approach

The project catalyst noted inconsistencies in providing diagnosis-related, evidence-based interventions to all applicable patients. This resulted in varied patient outcomes. In February 2013, the readmissions team, in conjunction with the hospital's home health agency, implemented 10 telehealth monitoring units. Patients were identified as potential telehealth patients through a readmission risk assessment that is completed upon admission into the facility. In fall 2013, the team was restructured to include additional members to enhance education efforts. Members from respiratory and the cardiac rehab departments were added. In December 2013, disease-specific education was provided through specific content experts. This started the foundation of a therapeutic relationship not only on an inpatient basis, but allowed the relationship to continue into an outpatient setting. The finalized data for Q4 2013 shows significant decrease in 30-day readmissions for three out of our four areas from data ending Q4 2012. As of the end of Q4 2013, there has been an overall decline in all conditions rate by 4.4 percent, heart failure by 8.57 percent and pneumonia by 15.34 percent.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)