Managing the Continuum

Reducing readmission rates

Mayo Clinic is also starting with the front end as it works to improve the care continuum. In 2007 the organization instructed clinicians at its Rochester campus to start focusing on three high-risk conditions for readmission: heart attack, heart failure, and pneumonia.

“Those are conditions that have high readmission and some of them are avoidable—and if it’s avoidable it could very well mean something was missed,” Simmons says. “This was directed at creating a much more intense and focused transitioned care program.”

Mayo physician and nursing leadership created a multidisciplinary committee to brainstorm simple, in-room tools that patient navigators, nurses, and physicians could use to ease the patient’s transition from the hospital to the home or rehab center.

They decided to begin using the teach-back technique—asking patients to teach the instructions back to the nurse or doctor who just explained them—and increased the number of follow-up calls and home visits they made to discharged patients.

Data shows that internal medicine reduced readmission up to 50% since the project began. Overall, the health system reduced readmissions by one-third.

“Most people who are readmitted come back to the hospital for two reasons: They don’t have a primary care physician, or they don’t have any education regarding medications and the meds aren’t appropriately reconciled,” Thaker says.