Anatomy of a Readmissions Master Plan

Jim Molpus, for HealthLeaders Media , November 14, 2013

The crux of Memorial Hermann's initial work in preventing readmissions has been in the expanded role of case management, which has evolved over the past seven years from a traditional inpatient episode role to one that takes a broad, continuum-spanning view of a patient's care. Pat Metzger, RN, chief of care management at Memorial Hermann, says the staff case managers at the system's 12 hospitals follow up daily once the system has identified patients as a risk for readmission.

"At each of the campuses, the case management staff has what they call one-minute rounds," Metzger says. "They go up on the units each morning and they meet with the nursing staff to ask, 'Who have we got today that we need to consider as high risk for readmission when discharged? Who was the new admission? What are their care needs that are driving this hospitalization? Who do we have that we're planning on sending home today? Have they met all their milestones?' "

The case manager makes certain that every discharged patient has a plan that maximizes the ability to avoid a readmission, Metzger says.

"No. 1, our case managers in the hospitals are focused on making sure that we're putting together a discharge plan that is the most cost-effective, but the least restrictive for the patients," Metzger says. For example, the case managers will review options for home health and other postacute providers that "we know we can trust to try to manage that patient in the ambulatory setting."

The staff case managers are "making every effort to get patients connected to the services that they're going to need back in the community before the patient leaves the hospital," Metzger says. Case managers will make the necessary doctor appointments for them, either within the Memorial Hermann physician staff or at area clinics. The case managers also coordinate with Memorial Hermann's ambulatory case managers to share care plans and to ensure there are no gaps in the care transition.

Case managers coordinate the discharge planning efforts, which are communicated via the health system's EHR platform.

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