Reducing Readmissions Through Better Care Transitions

Rene Letourneau, for HealthLeaders Media , June 16, 2014

"It has transformed our relationship with nursing homes," she says. "We always struggled with that because our system of communicating with them was archaic. With the EHR we were able to launch open access to medical records for their patients in addition to what we were doing with verbal handoffs, either nurse to nurse, or physician to physician."

Its enhanced relationship with nursing homes has helped URMC keep people from returning to the hospital, Berliant agrees. "There have been several cases with nursing homes where we have been able to empower them to take care of people who have complex diseases and help them manage those people onsite instead of in the hospital."

Still More Work to Do
So far, URMC has seen about a 5% drop in readmissions, which is an indication that there is more work to be done and that the program needs to be refined, Berliant says.

"One example is we thought early discharge follow-up would be tremendously advantageous, but only 60% to 70% of patients are able to be seen by their primary care doctor before being readmitted," he says.

"We have to keep putting these processes in place and getting people ready for discharge. We are also working on establishing a real willingness on the part of the primary care practice to see the patient quickly and on adequately communicating with the primary care physician so they can be prepared for the visit."

Berliant says being realistic about preventing readmissions is also necessary given the medical realities that many patients face.

"Some patients are going to come back no matter what you do," he says. "They just are not going to be kept out of the hospital due to multiple comorbidities. That is recognized nationally, and we wish CMS would recognize that as well."

A HealthLeaders Media webcast, A Comprehensive Readmissions Solution—Getting Process and Data Right, will be broadcast on Wednesday, June 25, 2014, from 1:00–2:30PM ET. Join leaders from Baylor Heart and Vascular Hospital and Southwest General as they reveal how adopting a hospital-wide culture of end-to-end care can reduce readmissions rates, improve patient experience, and foster physician engagement.


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