Although the readmissions approach at Pennsylvania's PinnacleHealth System isn't as centrally organized as its operations to cut infections, its approach to curb readmissions is nevertheless robust, Dana Kellis, senior vice president for medical affairs and chief medical officer, writes in a Hospital Impact blog post.
PinnacleHealth tracks readmission rates by physician and disease state to pinpoint and engage physicians or groups that have high rates and then notifies nursing homes. Case managers and executives work with them to implement alternative approaches to end-of-life care.
In addition, the system works on improvements during the discharge process, including phone calls to all discharged patients, specifically asking them if they started their medication and had follow-up medical appointments. The hospitalist team also helps clearly communicate the discharge plan. "The program has made a positive difference in our readmission rates," Kellis says. --Read the full Hospital Impact blog post