Page 4 How the US Health Care System Can Reduce Avoidable Read missions

LEARNING BY EXAMPLE Refining Processes in Hospitals for Smoother Transitions
Watch a video about
how the P2 Collaborative AF4Q alliances are working alongside local hospitals to identify processes that can be improved to
of Western New York help patients transition home. Aligning Forces Humboldt has supported St. Joseph Health System-
is implementing a care
transitions program to Humboldt County in changing its discharge processes to ensure patients identified as high risk for
give patients one-on-one readmission get needed follow-up care with primary care physicians and specialists. St. Joseph’s Care
support after leaving the
hospital. Transitions Program engages nurses to serve as transition coaches, assisting patients with medication
self-management, educating them on their conditions and the importance of keeping a personal health
record, and linking them with primary care providers. The transition coaches work with patients
several times before they leave the hospital. Since patients in the program are not receiving follow-up
care through home health, hospice, or a nursing home, transition coaches follow up by calling patients
within 24 hours of discharge and making a home visit shortly thereafter. Since 2009, St. Joseph’s has
cut its readmission rate by 20 percent.
Additional hospitals that participated in the Hospital Quality Network employed similar quality
improvement strategies to improve care transitions. Marymount Hospital in the Cleveland Clinic
network in Garfield, Ohio, implemented “Heart Failure Care Advocates” to help patients manage
their conditions after leaving the hospital. Care advocates acted as intermediaries between patients,
physicians, hospital staff, and caregivers to ensure that patients received recommended care while in the
hospital and were given comprehensive discharge plans, including medication and dietary instructions.
Care advocates also confirmed that a family member or caregiver would assist the patient at home
and made follow-up calls to check on patients soon after discharge. During the program, Marymount
reduced its 30-day all-cause readmission rate by 13 percent and maintained 100 percent compliance
with core measures for heart failure care.

Samaritan Albany General Hospital in Albany, N.Y., focused on reducing preventable readmissions
for heart failure patients by implementing a comprehensive patient education program. The hospital
standardized its congestive heart failure education materials, distributed “Heart Failure Care Kits” to
patients soon after being admitted, and implemented the teach-back method, which asks patients to
repeat instructions in their own words. Samaritan Albany General also began making follow-up calls
after discharge, and engaged different providers, such as pharmacists and nutritionists, to meet with
patients and answer questions during their initial hospital stay. Through the program, the hospital
reduced heart failure readmissions from 23.6 percent to 11 percent.
Oregon Health & Science University (OHSU) in Portland, Ore., also worked to help patients
understand their discharge plans better. After learning that patients were overwhelmed with
paperwork after leaving the hospital, OHSU staff members engaged a health literacy expert to
simplify and minimize discharge instructions to make them patient-friendly. Discharge instructions
were consolidated from an eight-page document written at a 12th-grade reading level to a more
easily understood one-page document written at a 6th-grade reading level. The hospital also
asked nurse practitioners to use the teach-back method during discharge, and offered a disease-
specific education booklet to heart failure patients. Over the 18-month program, OHSU reduced
readmissions for heart failure patients by 11 percent.

Additional Resources from RWJF:

Care Transitions Program Reduces Readmissions in Humboldt County
Nurse Care Advocate Improves Heart Failure Care
Samaritan Albany General Hospital Improves Patient Education
Heart Failure Education Reduces Readmissions

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