Breaking the Cycle: Care Coordination Interventions and Sickle Cell Readmissions

Approximately 100,000 people in the United States are affected by sickle cell disease (SCD). Sickle cell disease represents one of the highest readmitting diagnoses at this organization. The purpose of this study is to determine the impact of implementing care coordination interventions to reduce hospital readmissions of patients with SCD.

The setting for conducting the interventions took place at the flagship hospital of a seven hospital system in Houston, TX. The hospital is a not-for-profit, faith-based, 907-bed academic facility that provides highly specialized health services to the community and the world. The population of focus was adult patients (18 years of age and older) admitted to the hospital with a primary diagnosis of SCD.

Two interventions were implemented: Disease-specific discharge education and scheduling postdischarge follow-up appointments prior to discharge. These interventions were conducted by bedside nurses, case managers, and SCD champions over a 6-month period. The 30-day readmission rate for SCD was reduced by 22%. There was also a 0.9-day reduction in length of stay and a 17% reduction in emergency, observation, and inpatient encounters of patients with SCD.

This project found that implementing evidence-based care coordination interventions can reduce the 30-day readmission rate for patients with SCD. Implementation of effective evidence-based care coordination is a key aspect to reducing hospital readmissions of patients with SCD. Partnering with community networks is also important in addressing readmission risk factors including management of social determinants of health that increase hospital visits. Consistent, patient-centered education using simple and convenient tools helps improve understanding, applicability, and self-care management.