Innovation Spotlight - Triple Aim: New York Hospitals Are Improving Health, Enhancing Quality, and Reducing Costs.

South Nassau Communities Hospital Reduces Readmissions

While clinical care practices affect 30-day readmission rates, many circumstances, including sociodemographic factors, are beyond a hospital’s control. However, studies demonstrate that engaging patients early in the admission process and developing an appropriate post-discharge plan can impact the need for readmission. To that end, South Nassau Communities Hospital implemented a proprietary software program called “RightCare” that helps reduce readmissions by identifying patients at risk for readmission and recommending the appropriate level of post-acute care.

At the time of admission, intake nurses and case managers ask patients a series of evidence-based questions to identify and stratify their risk for readmission and evaluate their potential need for and level of post-acute care services. The software then assigns “scores” to patients, matching and connecting them to their post-acute care needs and services. Finally, the referral is transmitted to the appropriate agencies that are connected to the software product. As a result, patients who received the recommended level of care had a 34% lower readmission rate than patients who received less care than was recommended.

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