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One Organization's Readmission Reduction Best Practices

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Thursday, June 14, 2018

The success Covenant Medical Center in Lubbock, Texas, experienced readmission reduction is due to the regional approach.

This regional approach that is taken consists of:

  • Multidisciplinary Case Review—Includes provider specialist for cardiac and orthopedic readmission cases, with formulation of plans for improvement.
  • Readmission Reduction Committee—Chartered as committee of the Texas Regional Clinical Council to focus on reduction of readmissions in high-risk populations. 

The readmission reduction committee objectives are as follows:               

  • Determine valid, reliable data source for readmission data and create reports for review/analysis.
  • Perform multidisciplinary (care management, quality, physician specialist—cardio/orthopedic) case drill down on all readmissions within the focus population groups. 
  • Based on review/analysis, develop strategies to improve practices related to readmission reduction, including improvement in evidence based clinical care, care transition practices, community partnerships and collaboration, patient/family partnerships, medication reconciliation, and etc.
  • Based on strategies, create detailed project plans/tactics and include as RRC Addendum to Regional Strategy for Readmission Reduction/Seamless domain.
  • Mobile Integrated Health—collaboration with local paramedics to bring care to patients in their homes.
  • Educate physicians and nursing staff members on identified barriers, challenges, and opportunities.
  • Partner with community and local specialized care providers (clinics, dialysis centers, nursing homes, skilled nursing facilities, and other healthcare centers) to optimize patient health.
  • Use the Covenant Health Plan Navigation team on high-risk patient population, to aid in identifying opportunities, barriers to self-care, and minimizing those risks.

For more information, please contact Cherrideth Orr, BSN, RN, CPHQ, Lead Quality Specialist for Covenant Medical Center, Covenant Health/Providence St. Joseph Health, at csorr@covhs.org.