The Informer Monthly
Designing a Program to Prevent Unnecessary Readmissions

Robin Shannon, Director of Performance Solutions By Robin Shannon, RN
Director of Performance Solutions

Because the CMS Hospital Readmissions Reduction Program is in effect this year, you need a solid plan to reduce patient readmissions in order to avoid penalties. As the front door to your hospital and often the only area that many patients see, a strategy that starts with managing discharged emergency department (ED) patients with an actionable workflow and process redesign will offer the highest impact.

According to a recent report in the Journal of the American Medical Association, "An improved understanding of how the ED setting is best used in the management of acute care needs – particularly for patients recently discharged from the hospital – is an important component of the effort to improve care transitions.

Several factors make the ED the most logical place for readmission strategies to focus:
  • Nearly eight percent of patients recently discharged from the hospital will be seen in the ED within 30 days.
  • ED visits account for 40 percent of post-discharge hospital-based acute care use.
  • The ED is a major entry point for admissions with 50-70 of every 100 hospital stays originating in the ED.
  • For many patients, the ED is their only source of primary care and treatment of chronic conditions.
Start with goals

Understanding where you want to end up is vital to ensuring you end up there. In order to achieve your broad mission, you should define each goal specifically. While your mission might be "reduce unnecessary readmissions by 20 percent," this can be broken down into specific, defined component goals. Examples could include:
  • Notify PCPs when their patients are seen in the ED.
  • Identify all patients presenting to the ED who don't have a PCP.
  • Match 90 percent of ED patients without a PCP to an affiliated practice or clinic.
  • Enroll all ED patients with CHF in the disease management program.
Keys to successful goals
  • Make them SMART – specific, measurable, attainable, relevant and time-bound. Defining SMART goals will help ensure your entire team is focused and understands what you want to accomplish, when you want to accomplish it.
  • Establish a baseline. If your goal is "match 90 percent of ED patients without a PCP to an affiliated practice or clinic," what is your current rate?
  • Walk before you run. Select only one or two component goals to get started.
Develop a plan

Do your research. Look back over the previous three to six months to identify patterns in readmissions that could have been prevented through better care coordination. High-risk patients with chronic disease states (e.g. CHF, CAD, and COPD) or patients that don't have a PCP could be the ideal groups to start with if they're seen in your ED often.

Identify a multidisciplinary team. Include members from a variety of stakeholder groups, such as ED, case management, discharge planning, social work, community physicians and patient financial services. Success will require collaboration. Name a team lead and an executive sponsor to ensure organizational support.

Select helpful tools. Information technology is available to manage patient transitions. The ideal system will automate many of the tasks, provide actionable information to the right members of the care team at the right time and provide analytics that allow you to manage readmission risk. It should be easy for all team members to access on-line, define tasks to be done, track patients, identify target patient populations and deliver the medical record of the ED visit to the next care setting.

Use the 80/20 rule. Define the scope of the plan and keep it manageable. You can achieve meaningful results from small but targeted efforts. Approaching the plan in phases is fine. You can expand later. Design a process that addresses the changes you want to make. Map out each step of the new workflow process and define who, what, how and when for each step. For example, if planning for the goal, "All patients admitted in the last 30 days will be evaluated by case management upon arrival in the ED to identify ongoing care needs," you will need to determine:
  • How will we identify if an ED patient has been admitted in the previous 30 days?
  • Who will notify case management of their arrival in the ED?
  • How will the case managers be notified?
  • What will be included in the evaluation?
  • Who will take action on the desired results?
  • Etc.
Get started
  • Begin with only one of the component goals with a small target population. Don't try to do too many things at once. Focus on doing the smaller parts well.
  • Monitor the workflow. Make sure that all involved groups are following the new process.
  • Don't underestimate how difficult change will be. You are redesigning processes that have likely been in place for a long time – this isn't easy.
  • Stick to the plan that you have designed for at least 30 days. The team will have many new ideas, so it can be tempting to modify the program too soon.
Review results
  1. At the end of the first 30 days, measure your progress. Compare your current metrics to the ones collected before the start of your program. Readmission rates typically don't drop rapidly, but your component goals should show improvement.
  2. Use the reports from the tools you have selected to reduce the manual data collection needs.
  3. As a project team, discuss the lessons learned and suggestions for improvement.
  4. Quantify the results and communicate findings to other stakeholder groups. A visual chart with a quick summary is a great way to share information.
Revise plan as necessary
  1. Based upon results, metrics and suggestions, discuss revising the plan as necessary. Get input from the entire project team and other stakeholders.
  2. The team should consider how changes will impact the overall goals. Think through how any new changes will affect the existing plan.
  3. Make the necessary changes and document the new workflow. Be sure to determine the who, what, how and when for each new step.
  4. Communicate the new process to everyone involved.
  5. Continue to monitor and track progress toward your goal. Display your trending charts where staff can see the progress that has been made.
Expand the program

Now that you've had success with one component goal, it is much easier to expand the program to include the next goal using simple steps:
  • Identify the next patient group you'd like to manage.
  • Work through the above steps again to plan, implement, review and revise.
  • Continue to track and monitor progress.
Because the ED is a primary point of patient entry into the hospital, it is a good place to start addressing the readmission problem. Following the steps outlined above is critical for success. T-System can help. To speak to an experienced professional that can help you define your strategy, contact us today.

If you have questions or comments about this article, please contact Robin Shannon at

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