Readmissions to hospital – Potential actions related to processes of care

Updated as of January 22, 2016 Indicators based on administrative data tend to be the oldest of all indicators in D2D. Improving the timeliness of administrative data is a priority for AFHTO and HQO and others. And in the meantime, there are things teams can do to use these “old” data to fuel current, local efforts to improve. Assuming you have established that the data are good enough to direct action AND that improving performance in this area is a priority for your team, you may wish to discuss the following options with your clinical leaders, Quality Improvement committees, team staff and/or patients:

• Collaboration with HealthLinks
• Use of Patient Navigators
• Since some of the reasons for readmission include lack of coordination or delivery of home care supports and poor patient compliance with discharge instructions, follow-up after hospitalization might help reduce readmissions. Ideas to increase follow-up include
  • Train administrative staff (e.g. reception) to call patients who were recently in hospital or ER to set up follow-up appointments, with or without a triage process informed by clinical staff to exclude those for whom follow-up is not needed.
  • Implement electronic reminders in EMR to prompt clinicians to decide if follow-up is necessary and if so, who should do it (i.e. physician, other clinician) how (i.e. phone or in-person) and when, so that the health team staff can initiate the follow-up process.
  • Share follow-up rates with providers (anonymously or shared within the team) for their review to identify potential areas to intervene to prevent readmissions, if possible.
• Contact your peers to determine their performance and work with them to either spread any processes they find have helped them or collaboratively test some new changes that might work for you AND your peers. To that end, consider reviewing the following presentations from past AFHTO conferences to find out more about how teams are keeping people at home and out of hospital
  • Reducing the revolving-door syndrome: hospital and primary care working together to reduce 30-day readmission rate for COPD and CHF patients
  • The evolution of telehomecare: targeting more chronic conditions and offering customized approaches
  • Aging at home: Interprofessional care to keep seniors home and out of hospital
  • Post-hospital transition of care: from hospital to family practice