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.