Hospitals in pursuit of excellence

Readmission Rate Reduction

Pekin (Ill.) Hospital used plan-do-study-act with evidence-based practice research, guidelines recommendations from the Hospital Engagement Network and patient feedback to create a care transition program to reduce all-cause, 30-day readmission by 20 percent. 

The program provides individualized multi-faceted support to the patient when they are admitted and extends beyond discharge to improve the patients' self-managed care and outcomes. The care transition coordinator, with the assistance of the physicians, case managers, social workers, pharmacy staff and outside agencies, assists the patient with follow-up appointments and medication management, weight and blood pressure monitoring, and improved education. 

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state.  These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care. 

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)