Successful initiative cuts readmissions

Follow-up calls are a key component

After Bassett Medical Center in Cooperstown, NY, began a multidisciplinary program to reduce readmissions, the 30-day readmission rate for high-risk patient diagnoses dropped 70% from 13.4% in 2009 to 0.7% 2010. The initiative earned the medical center a Pinnacle Award for Quality and Patient Safety from the Hospital Association of New York State.

"We recognized that we had the opportunity to improve our overall readmission rates, not just for high-risk patients," says Lorraine Stubley, RN, MS, senior director of care coordination. "We knew that we weren't doing that badly, but there was still room for improvement."

The initiative includes assessing all patients for risk of readmission, creating easy-to-understand discharge instructions, making follow-up calls to at-risk patients, overcoming barriers to follow-up care, developing alliances with post-acute providers, and enhancing communication with primary care providers and specialists.

A key component of the readmission reduction project is the Society of Hospital Medicine's Project BOOST (Better Outcomes for Older Adults through Safe Transitions). Stubley and Komron Ostovar, MD, FHM, a Bassett hospitalist, were appointed to lead the multidisciplinary effort to develop a comprehensive care transitions approach to reduce readmissions. The hospital is an official Project BOOST site and works with a mentor who provides telephone consultation, teleconferences, and site visits, Ostovar says.

Although Project BOOST is designed for use with older adults, the Bassett team decided to expand the program and use it for all patients. Stubley says: "We found that age is only one factor that can put patients at risk for readmission. In our area, we have some very healthy older people and some young people with a lot of health problems."

Early on in the inpatient stay, case managers assess patients for their risk of being readmitted. Some of the factors they consider are principal diagnoses, medication changes, polypharmacy, psycho-social issues, health literacy, prior hospitalizations, and need for palliative care. When the assessment indicates that patients might be at risk for readmission, the case manager adds the letter "Q" to the electronic medical record, which alerts the treatment team.

Heart failure and diabetes were among the most frequent diagnoses of readmitted patients, Ostovar says. Oncology patients who have uncontrolled pain also were frequent readmissions, along with other patients who have palliative care needs that in the past were not identified early and treated aggressively, he says.

Stubley and a pulmonologist conducted a study on readmitted pneumonia patients and determined that many of the patients had end stage chronic obstructive pulmonary disease. They needed palliative care or hospice care but had not been receiving it. "We hadn't been having the difficult conversations with patients to discuss palliative care and hospice. This was one of our biggest opportunities to reduce pneumonia readmissions," she says.

The team examined evidence-based behavior and following the Project BOOST guidelines, developed a comprehensive care transitions approach. Ostovar says: "We worked for more than a year designing the program, [then] implemented the program on a medical unit."

The hospital hired a patient services coordinator who calls at-risk patients within 72 hours after discharge. The coordinator checks on their progress and answers any questions. The coordinator also makes sure they have filled their prescriptions and have a follow-up appointment with their primary care physician or a specialist. The patient service coordinator calls about 100 high-risk patients a month who are at risk for readmissions and follows up with patients who have heart failure, pneumonia, diabetes, or cardiac surgery. The ultimate goal is to call every patient discharged from the hospital within 72 hours.

In addition, patients being discharged receive an "800" number they can call any time between discharge and their first follow-up appointment if they have any questions or concerns. Stubley adds: "The number connects them to a case manager or social worker. It's been a tremendous opportunity for us to take care of any problems while they are still small."

Under Ostovar's leadership, the hospital revised its discharge instruction forms to make them easy to understand. "We know that you can have the best possible plan in mind, but if the patient goes home and goes back to taking the medicine he took before being hospitalized or doesn't understand when to call the doctor, he's likely to be readmitted," he says.

The revised discharge instruction forms use layman's terms instead of medical terms. For example, the hospital changed the term "principal diagnosis" to "why I was in the hospital" to make it more understandable. When the team asked for comments on the new discharge instructions at a community forum for further input, participants asked, "What is a PCP?" This question prompted the team to spell it out on the form.

The hospital changed its case management model to assign case managers by unit, which improved communication with the bedside nurses. "We have been working to take down the barriers one by one," Stubley says. For example, transportation is a significant issue with some patients. Hospital leaders set up an account with a cab company. Staff members give patients a voucher, which guarantees payment for transporting patients to their physician visits.

When case managers, nurses, and physicians provide education for patients and family members, they use the "teach-back" method to ensure that they understand.

The case management department has worked closely with area nursing homes and home health agencies on how to improve transitions in care. In addition, the patient services coordinator has developed key relationships with the largest volume clinics and specialist offices who serve Bassett patients. "When they know one of our patients is at high risk for readmission, they accommodate them with a timely appointment," Stubley says.


  • Lorraine Stubley, RN, MS, Senior Director of Care Coordination, Bassett Medical Center, Cooperstown, NY. E-mail:

For information on Project BOOST, visit