Patient screening and callbacks to prevent readmissions: a process improvement project

This process improvement project was to determine whether a telephone intervention could be successful in reducing readmission rates and to discover whether a screening tool accurately determines patients at high risk for readmission.

1. A screening tool may predict readmissions that could allow hospitals to focus resources and efforts where they are most needed. Case managers are well positioned to administer such tools. The Transitional CareModel tool did not work well for the University Medical Center Brackenridge population as administered. 2. Follow-up phone calls, though well supported in the literature, have an unknown effect as the calls made were on a focused population, identified by a screening tool that showed low accuracy in prediction.Further work in callbacks is warranted. 3. Patients who did readmit within 30 days of discharge were cared for by the internal medicine service 91%of the time. This represents an opportunity to focus resources and efforts between case managers and internal medicine providers without any screening methods.