Page 5 How the US Health Care System Can Reduce Avoidable Read missions

LEARNING BY EXAMPLE Improving How Health Care Providers Work Together
Watch a video about
how St. Joseph’s Health Changes driven solely by the hospital are not silver bullets for preventing avoidable hospitalizations—
System in Humboldt doctors, nurses and staff across all settings of care must work together for lasting change. For instance,
County, Calif., improved
care transitions for Central Maine Medical Center (CMMC) in Lewiston, Maine, a participant in the Hospital Quality
patients. Network, began working with Androscoggin Home Care & Hospice to provide needed, individualized
follow-up care. Nurses made home visits to every heart failure patient discharged from CMMC within
a week of leaving the hospital. After implementing this tactic, the hospital’s 30-day all-cause heart
failure readmission rate dropped from 22.8 percent to 17 percent.
Regions Hospital in St. Paul, Minn., also worked with care providers to ensure patients get necessary
follow-up care as part of its work in the Hospital Quality Network. After examining its discharge
practices, the hospital found that not only were heart attack patients responsible for scheduling their
own cardiac rehabilitation appointments, but also that the hospital did not have a consistent system
in place to recommend and track these follow-up appointments. Regions Hospital worked with its IT
staff to include a recommendation for cardiac rehab in discharge orders for heart attack patients. The
hospital used posters to engage nurses to notify the rehab staff of a discharge order recommending
cardiac rehab so they can then visit the patient’s bedside to schedule their first appointment. After
making these changes, referral rates to cardiac rehab at Regions Hospital rose to 60 percent higher than
the national average.

Del Sol Medical Center in El Paso, Texas, also faced the issue of heart failure patients not receiving
recommended care and returning to the hospital too often. Since heart failure was a common diagnosis
LEARNING BY EXAMPLE in the mostly Latino community, the hospital established a heart failure center to bridge inpatient
Watch a video about how and outpatient care as part of RWJF’s Expecting Success program. Nurses at the outpatient center
Androscoggin Home identified and visited heart failure patients in the hospital to educate them about tracking symptoms,
Care & Hospice in Maine
worked with patients to maintaining a healthy diet, monitoring weight and blood pressure, and taking medications consistently.
help them transition out They provided diagnosis information in the patient’s preferred language, referred patients to the heart
of the hospital.
failure center, and made follow-up calls after discharge to schedule a visit. At the heart failure center,
patients and caregivers could attend nutrition and health education classes and receive helpful tools,
such as a heart healthy cookbook, a scale, and bilingual calendars and diaries for monitoring blood
pressure, weight, and symptoms. After establishing the clinic, Del Sol’s 30-day readmissions for heart
failure decreased from 16 percent to 7 percent over two years.

Additional Resources from AF4Q:

Coordinated Home Care Reduces Readmissions
Improving Care Coordination by Streamlining Patient Referrals
Combining Better Systems and Intensive Patient Education for Better Heart Care

The initiatives in this brief prove that no one agent—not a health care organization or hospital—can
reduce avoidable readmissions on its own. Hospitals, primary care providers, local organizations,
patients and caregivers must all work together to coordinate care across entire communities to help
patients leave the hospital better informed and in a better position to get continuous care outside of the
hospital, so they do not need to return.

For more information about Aligning Forces for Quality, visit www.rwjf.org/qualityequality/af4q.

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