Reducing Readmissions Using Collaborative Care.

Area of Science:

• Healthcare Quality Improvement
• Patient Readmission Reduction
• Rural Health Initiatives

Background:

• Elevated 30-day readmission rates for Chronic Obstructive Pulmonary Disease (COPD) were observed in 2022.
• A rural, 116-bed acute care facility in Virginia identified the need for improvement efforts.

Purpose of the Study:

• To decrease 30-day readmission rates.
• To implement improvement efforts through an interdisciplinary team (IDT) approach.

Main Methods:

• A quality improvement initiative was conducted at a 116-bed healthcare facility in Southside Virginia.
• The initiative focused on patients aged 65 years or older discharged home or to assisted living with diagnoses of acute myocardial infarction, heart failure, COPD, and pneumonia.
• A collaborative IDT approach was employed to reduce penalty readmission rates.

Main Results:

• Readmission rates in 2023 met or fell below disease-specific targets for the four diagnosis groups.
• The collaborative IDT approach was effective in decreasing 30-day readmission rates compared to 2022 data.

Conclusions:

• Addressing community barriers and social determinants of health during the initial admission is crucial.
• Collaborative efforts among IDT members ensure a safe transition of care.
• The community paramedic program can provide valuable additional resources to rural communities.