IHA case studies

Decrease Readmission Rates within 30 days in the Medicare/Medicare Replacement Population for AMI, HF and PN


The health care system has been working to reduce acute care readmissions for the targeted population of AMI, HF and PN. An interdisciplinary team, called the transitional care team, consisting of a medication reconciliation pharmacist, a high-risk social worker and a project manager from quality was instituted at two hospitals. A transitional care nurse was added to the team in September 2013. The MRP reconciled medications at admit and discharge, striving for one source of truth. The HRSW performed an admission assessment, screened for palliative care, facilitated interdisciplinary conferences, arranged for services needed at discharge and made follow-up appointments with physicians prior to discharge. The transitional care nurse works closely with hospital staff, assists in follow-up calls, conducts disease-specific education, and builds a relationship with the patient and family members. The goal was to decrease avoidable readmissions within 30 days by 10 percent. The baseline was 20.14 percent from April 2011 through March 2012. This goal was surpassed with the achievement of a readmission rate of 14.15 percent from April 2013 through March 2014.

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.)

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