Adirondack Medical Center reviewed its 30-day readmission rate, and while their overall rate was lower than state and national averages, the readmission rate for its Medicare population was higher than average. So they decided to take action and established a multidisciplinary team to review patient intake and discharge processes, identify weaknesses, and develop action plans.
As a result of this work, the team re-instituted daily multidisciplinary rounds, revised the patient admission assessment tool, and created several new tools including a patient/family caregiver readmission interview screening tool and primary care provider identification tool. Additionally, staff, along with family and caregivers, began to prepare for the patient's release from the hospital by assembling key information into a newly designed discharge-planning portfolio. These folders contain, in one location, information related to patients' medications, follow-up instructions, planned provider appointments, and telephone numbers to facilitate contact and follow-up as needed.
Since these changes have been instituted, the 30-day readmission rate decreased by 47.7% for Medicare patients and 13.5% for all payers.