Reducing 30-day Readmissions, Simply

Care teams consisting of the hospitalists, nurses, case managers and social workers were created to work with patients to both educate them and to coordinate their care. Guided by the goal of creating better patient-focused care, teams use standardized care protocols in conjunction with electronic health records to treat the patients at highest risk for readmissions. Data is gathered at each encounter with the patient and made available in real-time to all members of the care coordination team.

This allows them to address and fix areas of concerns throughout the process. Trask says the EHR helps support and improve not only the physician's approach to care, but also serves to guide each member of the team to act in unison throughout the care continuum.

For instance, the nursing staff uses a pneumonia core measure checklist to ensure that things such as blood cultures are drawn in a timely manner.  Nurses and case managers assess the patient's literacy level and adjust educational materials and teaching methods to ensure that treatment and care instructions can be understood. Along with the data that's tracked and managed in the system, the nurses use white boards in patients' rooms to communicate essential information to both staff and patients.

Data evaluation and process improvement is carried out during meetings with hospital administrators, quality administrators, physicians, and nursing managers to assess the care coordination program and to review the core measures. Physicians are also given a scorecard so they can gauge their performance on key areas and benchmark that to the organization. They are also given information on which of their patients have been readmitted and why.