"For those situations, we're doing an actual call back to the facility to figure out what transpired on our side or their side to make sure we can keep patients from falling through the cracks," Gorman says. "If we have to change something, we'll use process improvement to do that."
Gorman and her team have also worked on standardizing paperwork that is exchanged between IU Health Ball Memorial and after-care facilities. And, if a patient does report back to the ED, they make sure staff internally and at the facility are informed. They are currently working on an EMR that all after-care facilities will be able to access, which is expected to be operational in early 2012.
For UPMC Hamot, Lancaster General, and IU Health Ball Memorial, the key to low readmission rates is the result of a combined effort of treatment guidelines, after-care partnerships, and intensive patient education and follow-up. It's a formula that other organizations can't afford to overlook.
"If you're not using order sets and patients aren't taking advantage of that postacute continuity of care that we're able to offer, they start bouncing back," Donnelly says.
This article appears in the January 2012 issue of HealthLeaders magazine.
Marianne Aiello is a contributing writer for HealthLeaders Media.