Hospital Spotlight: Oaklawn Hospital Tackles Readmission Rates

Posted on April 05, 2018

Hospital SpotlightReadmissions are characterized as patients who are readmitted to a hospital within 30 days of being discharged. Readmission rates are often used as a quality benchmark for hospitals and health systems.

Readmissions are a multifaceted and costly issue for hospitals; hospitals can be financially penalized for having higher than expected 30-day readmission rates for certain conditions, such as pneumonia and heart failure. They are also inconvenient and expensive for patients because additional days as an inpatient generate additional medical costs.

In September 2017, Marshall-based Oaklawn Hospital chose to tackle its hospital readmission rates, make it a primary focus area, and seek ways to reduce the number of readmissions within its facility.

Oaklawn initiated a two-pronged approach to reduce readmissions. First, communication and handoffs from one healthcare provider to another is an area where critical information can fall between the cracks. To address this, Oaklawn enhanced its daily multidisciplinary care conference, which includes physicians, pharmacists, laboratory technicians, respiratory therapists, physical therapists, home healthcare and case managers. Information from Oaklawn care managers in the primary care provider (PCP) settings were added to the conferences, allowing staff across the continuum of care to discuss each patient’s condition, discharge questions and concerns specifically related to potential rehospitalization.

The process for engaging the Oaklawn PCP care managers includes case management sending them a daily report that lists every admitted patient. The report is sent prior to the multidisciplinary care conference at the hospital, allowing the Oaklawn PCP care manager to review it and contact a case manager about any issues they need to be aware of for successful discharge planning. Care managers use this additional information during their post-discharge hospitalization phone calls to better stratify the patient’s risk for an unplanned emergency department or hospital visit. 

Oaklawn HospitalAnother important area of focus is performing warm handoffs when a patient is discharged from the acute care setting, where both the hospital case manager and the PCP care manager are physically present. Throughout the patient’s experience, the use of verbal communication is stressed, rather than total reliance on electronic health records. This helps to confirm all healthcare staff members are on the same page.

The second approach to reducing readmissions involves a partnership with CareWell Services, Calhoun County’s Area Agency on Aging. Hospital case managers and PCP care managers identify patients who would benefit from a home visit from a Community Health Worker (CHW). These patients do not qualify for other referrals, such as home healthcare or assisted living, but need additional help outside of the formal healthcare system. 

The criteria for a CHW referral includes patients who are age 60 or older, live in Calhoun County, have multiple chronic conditions, and experience at least one of the following: behavioral health condition, high utilization of Oaklawn services (emergency department or hospitalization), social determinants of health concerns, lack of support from family or the community, or being at risk for neglect/abuse or medication nonadherence. The CHW goes to the patient’s home to gather additional information that may categorize the patient as being at a higher risk for readmissions or need for healthcare services, as well as identify and activate community resources that will help meet the patient’s needs.

As of February 2018, only one of the 47 patients referred and seen by a CHW in the home setting was readmitted within 30 days of the community health worker referral.

Reducing hospital readmissions is no easy task. However, Oaklawn has been successful in its efforts, based on its ability to identify core issues and implement successful initiatives. At the end of the day, readmissions don’t just affect the hospitals — they affect the overall quality of care being delivered to patients. Therefore, Oaklawn hasn’t only successfully reduced readmissions within its facility, it’s also created a better transition of care for the communities it serves.

For more information on how to reduce hospital readmissions, register for the upcoming Great Lakes Partners for Patients Hospital Improvement Innovation Network webinar, “Reducing Hospital Readmissions – Part 4,” taking place April 18 from 2 to 3 p.m. This series will explore reducing readmissions through topics such as: Transitional Care Management (TCM) services, sepsis, behavioral health, and patient-centered approaches. Registration is free and open to all GLPP HIIN members.

This article was featured in the MHA Keystone Center Newsletter. To subscribe, please contact Ashley Sandborn, MHA Keystone Center communications specialist.


  • Hospital Spotlight: Oaklawn Hospital Tackles Readmission Rates

Tags: MHA Keystone Center, Patient Safety and Quality, readmissions

Posted in: Patient Safety & Quality

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