Over the last week, twenty of our FHA Mission to Care HIIN hospitals came together for an important networking opportunity and discussed best practice strategies for reducing hospital readmissions. Over 45 hospital leaders in care transitions, case management, readmissions process improvement, quality and patient safety participated in FHA Regional Readmissions Discussion Forums on May 17 in Jupiter, FL, and May 23 in Orlando, FL. Common challenges addressed were patients bouncing back to the hospital within seven days, identifying patients at greatest risk for readmissions, improving and standardizing the discharge process, scheduling follow up visits and reducing readmissions from skilled nursing facilities (SNF). Staffing and limited resources also continue to be a major barrier to preventing readmission.
The real value of these sessions is hospitals sharing their strategies such as creating a discharge lounge staffed by nurses and pharmacists where the plan of care is reviewed with the patient and their caregiver. The pharmacist reviews medications to determine if there are barriers, and can help schedule a follow up appointment. The discharge lounge also serves as the call back number if the patient has questions or is experiencing problems with their health. Another concept shared was using progression of care huddles, which are limited to one hour, to review each patient's readiness for discharge. Other ideas included using the readmission patient interview tool and including seven day readmissions in daily/weekly huddles. Involving pharmacists is key, especially to address medication issues. Partnering and meeting with the SNF, providing them feedback/scorecard on readmissions and engaging physicians from both settings can help to ensure a "warm" handoff of the patient.
The next regional Readmissions Discussion Forum is on June 15 in Pensacola, FL. Hospital care transition teams are encouraged to participate in this rare occasion to come to the table with their peers to discuss trends, activities and strategies for reducing readmissions. Register online today and Let's Talk!