Hospitals in pursuit of excellence

Fighting Readmissions with Care Coordination and Better Transitions

Reducing patient readmissions is both a critical patient safety need and a growing financial concern for hospitals. At Henry Ford Hospital in Detroit, a new pharmacist-directed anti-coagulation service is designed to reduce readmissions with a two-pronged emphasis on improved care coordination and smoother patient transitions after discharge. Pharmacists and physicians carefully determine the dosing and monitoring of patients in need of anti-coagulation treatment. At discharge, patients are educated on the risks of coagulation and are instructed to visit outpatient clinics for regular testing.ÿ The early results are promising: The program has achieved a 26 percent reduction in related readmissions within 30 days of discharge for participating patients. Henry Ford Health System plans to expand the program to its other six hospitals, and James Kalus, senior manager of Patient Care Services at Henry Ford Hospital, says the model could be adapted to manage patients with other chronic conditions. "We're focusing on anticoagulation, but the same issues exist with diabetes and other chronic disease states," Kalus says.