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Readmissions Huddles

The 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:
Create a culture of safety and communication around the discharge process by implementing “readmission huddles” that bring multidisciplinary personnel together around each recently-readmitted patient to share information and assess short terms and long-term system challenges for the organization.

Method & Implementation:
Self Regional Healthcare, using A3 and LEAN principles, began their readmissions huddles for individual patients that included staff from Case Management, Quality, home health, physicians, disease-specific navigators, and nurses. A huddle occurs when a team member determines a patient is suitable for discussion. Each huddle begins with a quick review of why the patient has been readmitted and what indicators they might have had at discharge that led them back into the hospital. The huddle will then move to short-term concerns for the patient (does the patient need palliative care? Home health?) followed by long-term thoughts about the organization is providing care (Did medication reconciliation work? Was the patient discharged on a weekend?).

Short-term items are assigned to specific staff and tracked, while long-term issues are filed away for discussion at a monthly process improvement meeting.

Challenges & Barriers:
Time constraints
Staff buy-in
Appropriately flexible huddle model

Reduction of low acute, non-emergent ER visits
Reduction of all-payer readmission rate from 13.96% in 2015 to 10.59% in 2016
Process improvement huddles have led to 90-day doctor-led teams for specific issues (COPD, Med Rec, etc.)
Collaboration and awareness of readmissions is at an all-time high

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