Phone Call Follow-ups and Home Visits to Reduce 30-Day Readmissions

Problem:
Ineffective care transitions processes lead to an increase in adverse events for patients, more frequent readmissions and higher healthcare costs. Studies show that nearly 20% of patients experience adverse events within three weeks of discharge, 75% of which are potentially preventable.

The Goal:
Self Regional Healthcare sought to improve readmission rates by altering their traditional communication and discharge strategies, including hiring healthcare navigators to visit high-risk patients at home.

Method & Implementation:
Self Regional took part in a collaborative program funded by The Duke Endowment called Preventing Avoidable Readmissions Together (PART). PART was established in September 2012 by the South Carolina Hospital Association, BlueCross BlueShield of South Carolina, Health Sciences South Carolina, and The Carolinas Center for Medical Excellence.

Self Regional launched several initiatives to improve the transition of care, most prominently a clinically focused follow-up telephone call and in-home visit with high-risk patients to facilitate the transition of care.

Challenges & Barriers:
Funding for full-time healthcare navigators to staff the program
Tracking accurate contact and address information
Ensuring nursing and social services staff had adequate knowledge to assist with the transition of care

Successes:
Reduction of low acute, non-emergent ER visits
Reduction of all-payer readmission rate from 13.96% in 2015 to 10.59% in 2016

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