Reaching Out to Reduce Readmissions William C Crowe, Jr, DNP, APN, ACNP-BC, FNP-BC; Paul M Smith, RN; Jodi Whitted, MSSW, LCSW Erlanger Health System, Chattanooga, TN INTRODUCTION With the initiation of CMS penalties for excessive readmission rates, hospitals have attempted to institute programs and methods to assist patients to avoid unnecessary readmissions. Excessive hospital length of stays are not feasible to prevent readmissions, and thus hospitals and physicians are tasked with both preventing readmissions and reducing length of stay. BACKGROUND The groundwork for reducing readmissions at Erlanger started several years previously as a pilot project for only those Medicare patients diagnosed with Congestive Heart Failure. Based on the success of the pilot program, the project expanded to cover five additional diagnoses for the Medicare population, and has further plans to expand a second time to include all Medicare patients regardless of the diagnosis. METHODS Erlanger Health System partnered with a Community Based Care Transitions Program (CCTP) which provides an in home visit within the first few days of discharge from the hospital. During this visit, the CCTP coach assists the patient with appointments, medications, and discharge instructions, as well as education on symptoms that require physician notification. Following the in home visit, the CCTP coach contacts the patient via telephone weekly for the next three weeks. For those Medicare patients not eligible for the CCTP program, a nurse from Erlanger calls the patient weekly during the 30 days following discharge. The nurse assists the patient with appointments, medications, transportation, and other needs as well as providing education on the disease process. The nurse performs telephone triage for those patients with symptoms and makes recommendations for additional follow up and interventions. Medicare patients are visited in the hospital prior to discharge by the hospital’s Care Transition Team which provides an additional opportunity for education and for explanation of the CCTP coach and Nurse Coaches. RESULTS Readmission rates are not significantly different between the Call Center and the CCTP coaches, indicating that effective interventions to decrease readmissions are possible without in home visits. Based on the success of the Call Center interventions, the Call Center expanded and is in the process of expanded further to reach all discharged Medicare patients. Additionally, the CCTP doubled the number of coaches making in home visits. The program’s largest successes have been with AMI, which dropped from a baseline readmission rate of 11.8% to 5.3 % and with pneumonia, which fell from 21.2% to 8.8%. PURPOSE The purpose of the project was to reduce the number of avoidable readmissions while minimizing the financial impact of governmental readmission penalties. CONCLUSIONS For a small department, the task of reducing readmissions can seem overwhelming. By evaluating each readmission thoroughly, and seeking out the cause of the readmission, trends can be identified and acted upon in order to reduce avoidable readmissions. As the CCTP was a community resource, all three major acute care hospitals participated, which has allowed the hospitals to work symbiotically to prevent avoidable admissions. Post acute discharge facilities have also become involved, and work with the CCTP and local acute care hospitals to better coordinate care and prevent avoidable admissions. FACTORS IMPACTING READISSIONS at EHS Medication Issues Prescriptions not filled Medications not taken correctly Follow Up Issues No PCP appointment Unable to keep PCP appointment Instructions Did not understand discharge instructions Missing written discharge instructions