St. Rose slowly expanded the scope of their readmissions program to produce a measurable change in readmission rates.
When we first began our program, we looked at our data to decide where to focus. We learned that most of our readmissions occurred on Sunday nights and were white women from Hayward. It was fine to start there because we only had one person to work with the patients. However, it’s hard to make an impact on your readmission rates when you’re only seeing a handful of patients every month. It’s also hard to tell bedside nurses that the program is only for a very specific population when they know that many other patients would also benefit from the program.
St. Rose is a non-profit hospital in Hayward, CA. It has 217 beds and serves a diverse, low-income population including Spanish, Hindi, and Tagalog speakers. Their transitions program began in 2012 and is influenced by Project RED.
What We Tried
We slowly expanded our staff and our target population to increase our numbers. At first we enlisted volunteers from the nursing staff to help with the patient enrollment and follow up phone calls. Then we expanded beyond our initial target of female patients in the PM shift to include anyone in the PM shift who nurses felt were at high risk to be readmitted. That worked well for a while, but ultimately the nurses were overwhelmed with the additional work they were taking on as volunteers. When it was clear they were overwhelmed, we started to hire non-clinical staff to do the enrollment and follow up phone calls. Once we had the staff (four people in total now), we were able look at all patients and screen for the high risk ones based on both medical and social factors.
We’re able to work with a lot more patients now. Rather than working with 10-20 patients a month, we’re seeing over 200 now and can really find the patients who need our help.
Keeping our numbers up is important, but we have to balance how many patients we work with and working with the patients where we can have the biggest impact. We found that it’s better to work with fewer patients who have CHF than more who have, say, a broken leg.