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P06 - Outpatient Care Coordination: Reduction of Readmissions Using Telephone Intervention

Background: Readmission rates for traditional Medicare at the hospital were 13.4% and 12.5% in 2019 and 2020, respectively, which are not within the desired readmission rates. To improve patient outcomes, reduce readmission rates, and ensure financial viability, the hospital embarked on a pilot project in October 2020 that targeted patients who meet the following criteria: discharge to home who are not on hospice services; at highest risk of readmissions based on readmission scores; diagnoses of acute myocardial infarction, acute and chronic congestive heart failure, pneumonia, and chronic obstructive pulmonary disease; and certain insurance coverage with Medicare.
Purpose: This outpatient care coordination pilot project provided patient assistance within 24-72 hours after discharge. The project ensured the care plan on discharge outlined in the after-visit summary is followed through for continuity of care. The plan of care may include a) follow-up appointments with primary care physician (PCP) and/or specialists; b) medication compliance and/or problems encountered on new prescriptions; c) home health and/or palliative care services as ordered; d) durable medical equipment and supplies are available as ordered; e) education on
disease process, medications’ indications, and side effects; f) provide PCP and specialists referrals as needed; and g) other health care needs.

Methods: Discharged patients are telephoned using structured interview questions to elicit patient needs or gaps in knowledge or care. These are then coordinated with departments and/or entities within and outside the hospital system to meet patient needs. These interventions reduced emergency room visits leading to readmissions.

Results: After five months of implementing the pilot project from October 2020 to February 2021, the pilot readmission rate was 5.14%. Compared to the hospital’s traditional Medicare readmission rate of 12.78% for the same period, the pilot project’s readmission rate was lower by 7.64%.

Evaluation/outcome: With the sustained positive outcomes, the pilot project was developed to become a permanent department of the hospital. Effective care coordination has shown improved patient outcomes and reduced readmission rates while ensuring the financial sustainability of the hospital.


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