Easing the discharge process through a comprehensive readmissions reduction plan

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Easing the discharge process through a comprehensive readmissions reduction plan

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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.

The Issue

Our data showed that in 2011 we were at a 9 percent readmission rate and the highest in the state of Oregon.


Location- Burns, Oregon.

Type- Critical Access Hospital.

Number of Beds- 25 beds.

Setting- Rural.

Payer Mix- 45 percent Medicare, 31 percent Medicaid, 21 percent private/commercial, and 3 percent uninsured.

Population served- Underserved.

Serving a population of less than 8,000, Harney District Hospital’s patient population is mainly from small ranching communities spread over 10,000 square miles. That land area is bigger than some states!

What We Tried

Harney District Hospital employs four distinct interventions to make up one comprehensive reducing readmissions plan. These four interventions are described below:

  • We organized a monthly readmission committee meeting that consists of the Utilization Review RN, Discharge Planner, Chief Nursing Officer, EMS Manager and Home Health Manager.


  • We implemented the LACE tool and follow-up calls within 24 hours of discharge. The LACE tool is completed by an RN or Unit Coordinator on every patient that is admitted acute. This tool is based on a point system. It is broken up into four categories, which includes length of stay, acute admission, comorbidity and ER visits during the previous six months. The Discharge Planner and Care Manager receive the tool if the patient has a score of 11 or greater, which increases their likelihood of readmission. These patients are monitored more closely, receive additional education and are followed up with for any needs that may arise when they return home.


  • We also began a more intensive patient education process using the teach back method, in which the nurse gives the patient their medication, the reasoning for medication and associated side effects. Then, the following day the patient explains what medication they are taking, the reason they are taking the medication and the side effects. This increases their knowledge base to prepare them for discharge home.


  • The Care Manager at the clinic also implemented the Harney District Hospital’s Family Care’s Care Management Program. The purpose of this service is to develop a team approach to achieve better health. The program recommends a group of patients that have been diagnosed with two or more chronic conditions to participate. The patient signs a contract committing to improving their health which includes home visits, communicating over the phone, visiting certain providers, etc. The Care Manager assists with navigating the system, including making appointments with the provider, answering any health care questions and supplying information needed to better manage their care and medications. They initially implemented the program using diabetics with chronic conditions closely managing their care, developing a comprehensive care plan and ongoing communication either by email or phone monthly. The patient was told to keep the Care Manager aware of any changes in their health and well-being. The Care Manager kept the lines of communication flowing with the primary care provider, community service providers, as well as any specialists. They assist with any coordination that helps the individual to receive all available services.


We decreased our readmission rate from 9 percent in 2011 to 2.6 percent in March 2015 through education and teamwork. From the Apprise Readmission Report (for April 2014 to March 2015), our hospital now has the second from the lowest readmissions rate in the state of Oregon.


Good communication with an understanding of the ultimate goal between staff and the patient is imperative. A true “buy-in” by both parties is important.

Program Challenges: Communicating with Patients

Patient and Family Challenges: Next Steps After Leaving the Hospital

Topics: Effective teamwork, Establishing a program, Measuring and improving

Collaborator (Non-Members): Cheryl Norton and Kelly Singhose

Organizational Background

Organization Name: Harney District Hospital

Location: 557 W WASHINGTON St, BURNS, OR 97720

Organization Type: Hospital