Better Care, Fewer Readmissions

Improving care after discharge translates to decreased readmissions. Marshall Medical Center, a 113-bed hospital in Placerville, Calif., used the AHA/HRET Hospital Engagement Network (HEN) change package driver to improve care transitions for discharged patients, reducing its readmission rate by more than 20 percent. With the change package, staff worked to ensure adequate post-hospitalization follow-up and use of community resources. The medical center implemented an EHR with clearly typed medication and discharge instructions. A discharge coordinator was hired to make special discharge phone calls to patients with selected high-readmission diagnoses and routine discharge calls to other patients. Expanded follow-up appointments are scheduled for all patients. Based on data analysis about patient compliance for follow-up appointments, these appointments are scheduled no longer than 3–5 days after discharge. Key to reducing readmissions is a multidisciplinary team with inpatient staff, hospitalists, and staff from clinics and skilled nursing facilities. In addition, the medical center involves the palliative care team for patients with end-stage chronic diseases to decrease their readmission rates. Since December 2011, Marshall Medical Center has reduced all-cause readmission rates from 13.2% to 10%.

For more information, contact Kassie Waters, director of quality management, at kwaters@marshallmedical.org.

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