Reducing heart failure readmissions required an organized, comprehensive approach at Mary Washington Hospital.
Heart Failure Readmissions: Pinpoint the Problem, Improve the Process
Cheri Basso BSN, RN, CHFN
Sakakawea Medical Center and Coal Country Community Health Center worked to improve their continuous care model to ensure patients consistently received warm hand-offs.
Commitment to Warm Hand-Offs Amongst a Complex System
Illinois Valley Community Hospital implemented a program combining elements of the Coleman and Naylor models.
Identify and prioritize transitional care program patients
Make changes to routine practices
Aledade Delaware ACO developed a population health management tool to more effectively coordinate care.
Implement admission, discharge, and transfer notifications in real time
Medicare beneficiaries take control of diabetes self-management
Care coordination helps lower the incidence of anticoagulant-related adverse events among Centura Health Medicare patients.
Reverse adverse drug events by establishing processes
Greenbriar Community Care Center’s re-hospitalization numbers decreased following data-driven interventions.
Drive facility interventions from data
The Cancer Center at Presbyterian Hospital initiated quality-of-life care planning to improve the patient care transition experience.
Assisting patients in creating a Quality-of-Life Care Plan
The development of a comprehensive chronic disease management program can significantly improve a patient’s quality of life.
Design targeted hospital units to communicate consistently with patients
Step into your Sunday Shoes to decrease heart failure readmissions
By standardizing verbal and written transitions processes, UW ensures accurate clinical information is exchanged.
Improving bidirectional communication between the emergency department and post-acute care facilities
The University of Wisconsin Hospitals and Clinics created a SNF-Acute Care coalition to address challenges of transitioning between settings.
Generate dialogue and implement changes by assembling a coalition
Scott & White Memorial Hospital & Medical Center improved medical management in SNFs to reduce hospital readmissions.
Creating improved medical management in community Skilled Nursing Facilities
To improve care transitions for individuals with cognitive impairments, Dominican Hospital developed a support care handoff tool.
Settle patients into their new environment with a handoff tool
Duke Children's Complex Care Service aims to coordinate longitudinal care across the continuum for children with medical complexity.
Improving care for children with medical complexity
Hallmark Health System, Mystic Valley Elder Services, Somerville-Cambridge Elder Services and Cambridge Health Alliance developed a program to enhance existing discharge practices and patient care at multiple service locations.
Building a care transitions model with a CCTP for high risk patients
One integral component of reducing our readmission rate from 9 percent to 5 percent was conducting 72-hour callbacks.
Connect and check-in with patients after discharge
We are a Critical Access Hospital that began with a 9 percent readmissions rate in 2011. Through team collaboration we have been able to decrease our readmissions rate.
Easing the discharge process through a comprehensive readmissions reduction plan
Duke has taken a broad approach to opioid safety. This has included developing guidelines and tools. The next step involves reaching out to our clinicians.
A health system approach to opioid safety
We reduced our readmission rate from 9 percent to 5 percent in a very short period of time. We are happy to share our tips while continuing to learn and improve!
Educating physicians to reduce readmissions in a rural setting
The E.C.H.O Program helped reduce the overuse of the emergency department (ED) as a primary care provider (PCP) by uninsured and underinsured patients.
Reducing emergency department overuse with the E.C.H.O Program (Emergency Care Helping Others)
We utilized LEAN performance improvement tools to analyze readmissions and implement improvements to reduce readmissions.
Patient centered approach to reducing readmissions
Following a patient death several days after discharge to home, HealthSouth Valley of the Sun partnered with a local pharmacy to deliver high-risk medications to patients' bedsides before discharge.
Establishing bedside delivery of high-risk medications following an adverse event