Patient centered approach to reducing readmissions

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Patient centered approach to reducing readmissions

< 1 minute read

We utilized LEAN performance improvement tools to analyze readmissions and implement improvements to reduce readmissions.

The Issue

Hospital readmissions are costly for patients, families and facilities by causing stress and burden of another hospital admission for patients. At St. Joseph’s Hospital, our readmission rate as reported by the Illinois Hospital Association (IHA) was at 15 percent for 2012-2013, above the state average of 13.9 percent. Not only is it important financially for the hospital, but it is important for us as a Catholic Health Care Ministry to exemplify both the Hospital Sisters love for all and the expectation of service before self and to also live our mission: “To reveal and embody Christ’s healing love for all people through our high-quality Franciscan health care ministry.”


Hospital Sisters Health System (HSHS) St. Joseph’s Hospital is a 25-bed critical access hospital located 30 miles east of St. Louis. HSHS has 14 hospital affiliates in Illinois and Wisconsin. We have a very tight-knit community that has more seniors than average Illinois communities. The education level in our primary service area has a higher-than-average number of residents with a master’s degree. Thus, they are educated, and when they come to the hospital, they have high expectations. Patients often come as a family, and we include family in the care plan.

What We Tried

We implemented a Community-based Care Transitions Program (CCTP). Components of our CCTP included the following:

-Utilization of Lean Performance Improvement tools to analyze data we collected helped identify root causes for readmissions. Several PDSA cycles were conducted on the components.

-Daily multi-disciplinary huddles prepared the patient for discharge and included nursing, rehab, pharmacy, cardiopulmonary, quality, case management, home health, infection control, pastoral care, wound clinic, senior renewal and cardiac rehab.

-Readmission screening was expanded to include all inpatients and was based on specific social and physical needs.

-Medication education was standardized and included a review of all medications by pharmacy.

-Discharge callbacks were reevaluated and increased to four with the content revised to include open-ended, patient-centered questions.

-We worked with the physician offices to revise the timing for follow-up appointments from seven days to three days post discharge.

– A case manager was relocated to the ED and conducted interviews with all patients to identify needs.


Patients have voiced their appreciation for both discharge callbacks and pharmacy rounding.

Results from the improvements mentioned above have been substantial. Our acute myocardial infarction, heart failure and pneumonia readmissions decreased from 13.6 percent to 6.3 percent.

According to our IHA readmission report, we have decreased our overall readmission rate by 25 percent. Our report from 2012-2013 showed our overall readmission rate (15 percent) was higher when compared to the state of Illinois (13.9 percent). The most recent report from 2014-2015 showed continued improvement at 11.5 percent compared to a state average of 14.1 percent.


The advice we would share with others is to complete your data analysis, implement actions that are meaningful and ensure that you evaluate those actions to make sure they have added value. We implemented weekly meetings to monitor our actions, thus increasing accountability.

Organizational Background

Location: 12866 Troxler Avenue, Highland, IL, United States

Organization Type: Hospital

Organization Model: Not Set