Skip to main content

One Organization's Readmissions Improvement Best Practices

Diverse Business Group Young Female Doctor
Monday, June 4, 2018

Readmissions Improvement Best Practices Using Strategies from St. Rose Hospital in Hayward, California:

  1. Risk Assessment is Completed (LACE* Assessment) on All Patients as Part of the Discharge Plan. Prior to discharge (DC), care coordinator meetings are held with patients and families about the DC plan, medications, etc. If no primary care physician (PCP) is available, the coordinators will establish relationships for the patients, according to their needs.
  2. Care Transitions and Call Backs Using a Care Transitions Licensed Vocational Nurse (LVN). This person works with patients on understanding, using the teach-back method, and interviewing for comprehension and assessment of communication barriers. Additionally, there are two patient care advocates (non-nurses) who follow up with patients. During follow-up calls, if a patient indicates he or she has questions or concerns, one of the advocates will call the patient back within 24 hours to address concerns.
  3. Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Care Communities When Patient Is Readmitted from a SNF. The patient care advocate sends an email notifying the administrator/nursing director of readmission. St. Rose established its care coordination community by holding quarterly meetings with HHA/SNF partners. The SNFs started developing their own care transitions tools. Care coordination meetings encouraged/facilitated sharing across SNFs and partners.
  4. Social Determinants and Homeless Support to Address Readmissions Among the Homeless Community. The St. Rose care transitions team worked with the Alameda county “Care Connect” program to provide a structure for behavioral health outreach, case management, follow-up appointments, medication distribution, and monitoring.

Next steps: December 2017 flu season impacted that quarter's quality improvement metrics, and St. Rose is now focused on reducing readmissions for sepsis, while maintaining its wins in reducing readmissions for Medicare Fee-for-Service (FFS) patients.

For more information on reducing readmission strategies used by St. Rose Hospital, please contact: Vincent Cachuela, BSN, RN, Manager of Case Management & Social Services, St. Rose Hospital at

*Length of stay Acuity of admission Comorbidities Emergency department visit in past six months