Readmission Reduction from Post-Acute Care Facilities

In response to high readmission rates coming from the health system's skilled nursing facility (SNFs) partners, it instituted a new comprehensive transition of care (TOC) model. The transition coach (TC) acts as a liaison between the hospital system and SNFs to prevent readmissions, facilitate problem-solving strategies and provide on-site educational support. TOC meetings are held bimonthly to share quality metrics with all partner SNFs. The model requires all SNFs to contact the TC about any potential hospital transfer to make every effort to keep patients as safe as possible, while preventing readmissions. The TC acts as a liaison between the hospital and SNFs, enabling increased collaboration on enhanced quality metrics, a focus on patients at high risk for return and targeted education.

This model enhances fiscal responsibility by allowing the TC to support more patients than could be served in models that send the TC into the home. It supports a generous-size population and complements the population health model the health system is moving toward.

This case study is part of the Illinois Health and Hospital Association's annual Quality Excellence Achievement Awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals and health systems in continually improving and transforming health care in the state. These organizations 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—and the Institute of Medicine's six aims for improvement—safe, effective, patient centered, timely, efficient, and equitable. To learn more, visit https://www.ihaqualityawards.org/javascript-ui/IHAQualityAward/