Bassett Medical Center in Cooperstown, N.Y., received a Pinnacle Award for Quality and Patient Safety from the Health Care Association of New York State in June, honoring Bassett's program for improving care transitions and reducing hospital readmissions.
Bassett used an evidence-based approach that incorporated readmission screening tools and risk-reduction strategies, a patient services coordinator to make post-discharge follow-up phone calls, and a toll-free number for patients to call any time prior to their first post-discharge medical appointment. The result was a readmission rate that was reduced by 25%, from 17% in 2009 to 13% in 2010. Thirty-day readmissions for high-risk patients fell 70% for the hospital, which is a mentored site in SHM's Project BOOST (Better Outcomes for Older Adults through Safe Transitions).
Hospitalist Komron Ostovar, MD, FHM, and Lorraine Stubley, RN, MS, the hospital's senior director of care coordination, led a multidisciplinary quality group that included primary-care providers and representatives from community settings. They worked to strengthen information flow between inpatient and outpatient providers. One of the most helpful tools, Stubley says, was Project BOOST's "8 Ps" for risk assessment, which identified high-risk patients consistently.
The care-transitions initiative also lays the groundwork for implementing a "geographical care model" at Bassett, with a universal bed unit staffed by nurses who are able to provide for all of the patient's needs for the entire hospitalization, she says.
The facility's hospitalists led daily rounds, emphasized teach-back education, and helped to refine discharge instructions in patient-friendly terms. "Our group of hospitalists understands that we now 'own' the complexity of care transitions," Dr. Ostovar says. "If we, as professionals, don't make every effort to get it right, then who will?"