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Connect and check-in with patients after discharge

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One integral component of reducing our readmission rate from 9 percent to 5 percent was conducting 72-hour callbacks.

The Issue

Our data indicated that from 2014 until June 2015, our readmission rate was 9 percent with no plan in place for improvement.

What We Tried

We implemented a plan for physician education (see “Educating physicians to reduce readmissions in a rural setting” story) but understood that this was not enough; we knew that we needed to follow our patients once they left the hospital to help them along and to try to ward off any complications that might cause a readmission. Beginning July 1, 2015, we began having our nurses make a follow-up appointment with each patient’s primary physician before they leave the hospital. That appointment is printed on the patient’s written discharge instructions and is also recorded in the EHR. Then, we have a Registered Nurse call the patient 24-72 hours after discharge to see how they are doing, go over their discharge medications with them, address any questions or concerns, and reinforce the importance of keeping their follow-up appointment. The nurse then calls the patient again the day after their scheduled follow-up appointment to make sure they went and to address any new questions or concerns. We found when looking at the data that the diagnoses with the highest readmission rates were congestive heart failure and chronic obstructive pulmonary disease, so the nurse also calls patients with those diagnoses at 14 and 21 days post-discharge to try to make sure that any pending complications are addressed at the clinic before they worsen and cause a readmission.

Impact

Our percentage of readmissions for July 1 – December 31, 2015 is down to 5 percent.

Additional Benefits

In addition to our in-house efforts, we were very fortunate to be contacted by our local health alliance about participating in a 3-year grant program that will provide a health coach to educate patients in the hospital and to follow them for 45 days after discharge at no cost to our facility. We are very excited to see how much our rates will decrease with our health coach on board!

Tips

To be successful, you must have support from your staff, your physicians and your administration. Education is key and numbers ALWAYS speak louder than words!

Heather Rogers

Profession:

Organization Background

Organization Name: South Sunflower County Hospital

Location: 121 E Baker St, Indianola, MS, United States

Organization Type: Hospital

Organization Model:

2 Comments
  1. Sue Collier 2 years ago

    Great point about education and data! One question: How are you using the information gained from the follow-up calls to identify other opportunities to improve patient care and education?

    • Author
      Heather Rogers 2 years ago

      Great question! We end up gathering lots of information from those calls, and we try to address any problems we come across. For example, a patient may mention that they didn’t pick up one of their discharge meds because it was too costly; in that situation we would try to find programs that might help or we may call the physician to see if there might be an appropriate substitute that is more cost-effective for the patient so that they can be compliant with their plan of care. Sometimes a patient may indicate that they didn’t fully understand their discharge instructions before they left. That would indicate to us that we might need to follow up with our nursing staff to ensure that they are providing proper education and see if there are any barriers that they may need help with. We also keep a spreadsheet of all calls made including the patients’ comments, and we share those comments at our monthly Department Head meeting so that we can identify any areas that a certain department may need to focus on.

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