Page 3 How the US Health Care System Can Reduce Avoidable Read missions

Identifying and Working With At-Risk Populations

Since reducing preventable readmissions is a formidable task, many organizations and hospitals begin to
tackle the problem by identifying patients who are most likely to return.

As part of its work with the Hospital Quality Network, the staff at Redington-Fairview General
Hospital in Skowhegan, Maine, examined trends across its heart failure patients to determine how
to recognize those at higher risk for readmission. The hospital chose to incorporate the hospital
“LACE” assessment, which calculates a risk score based on length of stay, acute admission through
the emergency department, comorbidities, and emergency department visits in the last six months.
For 18 months, Redington-Fairview tested the system by assigning LACE scores to each patient upon
admission. If a patient had a high score, care transition nurses closely monitored the patient and
provided more comprehensive education. During the 18-month trial, 30-day readmission rates for
heart failure patients decreased from 6.9 percent to zero percent.

Aligning Forces Humboldt, the AF4Q community in Humboldt County, Calif., works with St. Joseph
Health System-Humboldt County to identify and target patients who are frequently hospitalized and
provide them with intensive social services. The alliance estimates that these hard-to-reach patients fill
10–30 percent of hospital beds at St. Joseph, and that physicians often keep them hospitalized longer
because socioeconomic challenges prevent them from continuing to get healthier after leaving the
hospital. To address this, St. Joseph implemented the “Intensive Transitional Services Program,” which
tasks a nurse team and social worker with developing customized plans to help patients overcome
barriers for getting care and complying with treatment plans. The team works with community
resources to meet patients’ basic needs, such as food, housing and transportation, so patients can better
follow their treatment plans and get continuous outpatient care. By providing tailored, one-on-one
support, the Intensive Transitional Services Program helps patients, many of whom are homeless, get
and maintain jobs and long-term living arrangements. St. Joseph has seen a decrease in readmissions
and length of stay, as well as significant cost savings.

Six AF4Q alliances are also leading initiatives to provide support services to patients who receive
repeated care in emergency departments and hospitals, known as “super-utilizers.” These patients
often have multiple chronic medical problems and social complexities that prevent them from
managing their health, leading them to frequently receive care at the hospital, which is an expensive
and inefficient way to treat these patients. As part of the program, the alliances review hospital
records to identify super-utilizers in their communities, work with care teams to coordinate social
and medical services that patients need to stay healthy outside the hospital, and provide coaching
and support for primary care practices to help them provide targeted care and case management for
super-utilizer patients. The program aims to reduce unnecessary hospitalizations by engaging care
teams and primary care practices to work closely with patients to recognize and address barriers
for maintaining their health, and coach them on better ways to manage their conditions with their
doctors and caregivers.

Additional Resources from RWJF:

Promising Practices for Reducing Hospital Readmissions
How to Avoid Being Readmitted to the Hospital
Hospital Discharge Checklist and Care Transition Plan
Hospital Uses “LACE” Assessment to Reduce Readmissions
Robert Wood Johnson Foundation Awards $2.1 Million in Grants to Improve Care, Reduce Costs
for Most Expensive Patients
Better Care for Super-Utilizers

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