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One Organization's Readmission Reduction Best Practices

Senior Asian Couple Diverse Business Group
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