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Focus on Care Transitions to
Reduce Readmissions and Boost
Your Bottom Line


To improve your bottom line while also increasing safety and improving patient experience, consider an acute focus on reducing readmissions. Decreased readmissions lead to improved patient outcomes, which improve brand reputation, ultimately leading to increased patient volume and market share. This begins with creating a seamless care transition plan for what will happen within the hospital as well as after discharge.


How Readmissions Impact
Your Bottom Line

80% of hospitals face readmission penalties in FY18.

Of hospitals face readmission penalties in FY18.

$564 million in payments are being withheld in FY18 compared to $528 million in FY17 due to readmissions.

In payments are being withheld in FY18, compared to $528 million in FY17, due to readmissions.

20% of elderly patients end up back in the hospital within 30 days. This costs $26 billion annually – with more than $17 billion attributed to return trips.

Of elderly patients end up back in the hospital within 30 days. This costs $26 billion annually - with more than $17 billion attributed to return trips.


Reducing Readmissions Means Higher Net Operating Profit Margins

Net Operating Profit Margin by Hospital Return Days for Heart Failure Patients

Hospitals with Fewer Readmissions Have Lower MSPB

MSPB Score by Hospital Return Days for Heart Failure Patients

Reduce Readmissions By Improving Care Transitions

When patients and care providers aren't equipped with the knowledge and tools needed to transition the patient to the next stage of their care, patients are vulnerable to adverse outcomes while they are in the hospital or being readmitted after they are discharged. To prevent readmissions, focus on one of the most dangerous times for patients - handovers or care transitions within the hospital and upon discharge.

  • Estimated medication errors harm 1.5 million people each year in the U.S.
  • Annual cost: $3.5+ billion
  • 60% of medication errors occur at times of transition
  • There are more than 4,000 handovers a day in a teaching hospital

Techniques to Improve
Care Transitions

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Implement a patient communication framework

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Encourage staff to structure conversations with patients so they always acknowledge the patient, introduce themselves, state the duration of the process, offer an explanation and say thank you. This framework, AIDET®, decreases patient anxiety, increases patient engagement and improves clinical outcomes.

Provide clearly defined recommendations

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Use key words at key times to describe the situation, background, assessment and recommendation in a way that's easy to understand.

Implement nurse leader rounding/leader rounding on patients

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Visits to patient rooms by hospital and nurse leaders demonstrate the organization's commitment to deliver quality care.

Use a Bedside Shift ReportSM

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Have a conversation between the departing nurse, the arriving nurse and the patient which uses the teach-back method to confirm the patient's understanding of their care plan.

Provide patients with visit guides

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Use a customizable document to facilitate discussions, highlight care objectives and capture positive aspects of the encounter. Patients can refer to the guide upon discharge.

Create and review discharge folders

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Empower patients with well-organized post-care instructions.

Follow up with care transition calls

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Post-visit phone calls, also known as the "best four minutes in healthcare," are long-proven to drive stronger transitions of care by checking in with the patient once they're home.

Include entire care team

Include entire care team

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Coordinate with primary care physicians, case managers and essential partners such as pharmacy, as well as community resources, to help drive consistency and achieve desired results.


The Impact of Regional One Health's Centralized Care Transition Call Model

14.8% readmission rate prior to implementing the centralized care transition call model for sickle cell patients.

Readmission rate prior to implementing the centralized care transition call model for sickle cell patients.

$1.5 million In estimated cost avoidance.

In estimated cost avoidance.

2.5% Readmission rate 9 months after centralized care transition call model was introduced.

Readmission rate 9 months after centralized care transition call model was introduced.

To improve your healthcare organization's financial performance, drive down readmissions. This starts with an acute focus on care transitions. To do so:

Think Differently

Think differently.

Identify the pain points during the care transitions your that patients experience.

Plan Differently

Plan differently.

Implement standard processes and behaviors during care transitions and a plan for once they have been discharged.

Act Differently

Act differently.

Monitor readmission rates to identify areas where the patient experience can be improved.

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