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Published bySusan Summers Modified over 7 years ago
Good Samaritan Hospital Readmission Risk Assessment and Intervention Algorithm John Robinson, MD, VP Medical Affairs, Good Samaritan Hospital Theresa Wnek RN, Clinical Process Management Consultant
Project Selection Approximately 28% of readmissions are avoidable At the federal level, they estimate these readmissions account for over 12 Billion dollars Focusing on readmissions and creating a more collaborative approach provides: Safe transitions of care; A more integrated discharge planning process; and Better adaptation of the patient to their post hospital setting This focus on readmissions aligns well with TriHealth’s Strategic plan to become a leader in Quality, Safety and Service 2
Situational Analysis Through the participation of the STAAR Program, PDCA and small tests of change methodology were used to improve clinical outcomes Perform enhanced admission assessment for post-hospital discharge needs Development of a Readmission Risk Assessment Tool Creation of a tool to align readmission risk level with interventions Refine post discharge follow up care The aim was to: Reduce 30 day all cause readmissions Improve on the following 4 HCAPHS scores by Clear communication by nurses Clear communication by doctors Talking to patients about help after discharge Providing written discharge instructions 3
Readmission Risk and Intervention Algorithm 4
Results A clearly defined method to guide patient interventions from admission to the post discharge care A 20% increase in Top Box Score for Nurse Communication A 2-3% Increase number of home care referrals A 14% Decrease number of interventions required post discharge 5
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