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

Mount St. Mary's Hospital Reduces Readmissions

To reduce hospital readmissions, Mount St. Mary's Hospital and Health Center (MSMH) brought together its readmission and palliative care initiatives to implement patient-centered interventions and strategies to assess and manage vulnerable populations. MSMH identified and addressed gaps in care transitions through medication reconciliation, disease-specific education, post-hospital planning, referrals for high-risk patients, a discharge home guide for patients, a teach-back tool at the time of discharge to be sure patients understand the information being provided, and an emergency room diversion initiative. These efforts have led to a 22% reduction in the all-cause readmission rate over the last 24 months.