Reducing Readmissions Using Collaborative Care

After noting an elevated chronic obstructive pulmonary disease readmission rate for 2022, the inpatient Nurse Navigator at a rural nonprofit, 116-bed acute care facility in the State of Virginia met with interdisciplinary team (IDT) members to identify improvement efforts to decrease 30-day readmission rates.

A 116-bed health care facility in Southside Virginia.

Quality improvement initiative aimed to decrease 30-day penalty readmission rates using a collaborative IDT approach, focusing on patients 65 years or older who are discharged home or to an assisted living facility with a diagnosis of acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia.

Compared to the readmission rates obtained in 2022, the 2023 readmission rates among the four diagnoses groups met or were under the disease-specific targets for 2023, supporting the efforts of the collaborative interdisciplinary approach to decrease 30-day readmission rates.

Addressing community barriers and social determinants of health at the index admission. Collaborating with IDT members for a safe transition of care. Using the community paramedic program to provide additional resources to a rural community.