Hospitals in pursuit of excellence

Utilizing Software to Reduce 30-Day Readmissions

To help reduce 30-day readmission rates, South Nassau Communities Hospital implemented “Right Care,” a proprietary software program that identifies patients who are at risk for readmission and recommends the appropriate level of post-acute care. “Right Care” allows intake nurses and case managers to assign a score to patients based on a series of evidence-based questions asked at the time of admission. This score is used to match and connect patients to the most appropriate post-acute care services and provide direct referrals to agencies that provide these services. Since implementing “Right Care,” South Nassau Communities Hospital documented that patients who received the recommended level of post-acute care had a 34 percent lower readmission rate as compared to those that received less post-acute care than was recommended.

This case study is part of the HANYS Triple Aim series highlighting how New York hospitals are improving health, enhancing quality and reducing costs. Hospitals, nursing homes and home care agencies across New York state are pursuing the Triple Aim. In spite of fiscal constraints, its members are embracing the challenge of transforming health care and are implementing new and innovative approaches to delivery.