Decrease Readmissions and Improve Transition of Care

Hospital readmission shortly after discharge is increasingly recognized as a marker of inpatient quality of care and a significant contributor to rising healthcare costs. As noted by the Centers for Medicare & Medicaid Services (CMS), nearly one fifth of Medicare beneficiaries discharged from acute care hospitals are readmitted within 30 days, incurring additional costs of several billion dollars annually. Although it remains unclear whether such readmissions are entirely preventable, CMS proposes that there is good evidence that targeted interventions initiated before and/or shortly after discharge can decrease the likelihood of readmission. Identifying patients at risk of readmission can guide efficient resource utilization and permit valid comparisons of hospital quality across institutions.


Folowing the Project BOOST (Better Outcomes for Older adults through Safe Transitions) model to improve the care of patients as they transition from the hospital to home, we are piloting a post discharge phone call project to: (1) ensure they understood their discharge instructions (including medications) and answer any questions, (2) ensure they know when their next outpatient follow-up visit is scheduled and (3) monitor whether they are experiencing any untoward clinical symptoms. In addition, we are devising a process to alert patient care teams to 30 day readmissions in real time. Lastly, we are partnering with Infection Control practitioners to decrease surgical site infections (SSIs), which are the most common cause for 30 day readmission in the neurosurgical patient population.