• Innovation in Action

Jun 1, 2021

Risk Assessments Upon Admission, Follow-up Calls After Discharge, and Education Decreases Readmission Rates for Small Hospital

Southeast Health-2

Adding new processes and tools to patient rounds allowed Southeast Health Center of Stoddard County, a 48-bed (15 in-patient) hospital in Missouri, to reduce its readmission rate by just over 2% in a few months in 2020. After reviewing its data, hospital leadership determined they needed to focus on patient readmissions associated with congestive heart failure, pneumonia, and chronic obstructive pulmonary disease (COPD).

What Did the Hospital Change?

Every morning, a team consisting of staff from the hospital’s pharmacy, case management and social services, perform rounds with each patient and then the case manager completes a Readmission Risk Assessment Form, which is based off the LACE index. While many hospitals perform these risk assessments during discharge, Southeast Health Center of Stoddard County does this as soon as possible after a patient is admitted.

“Think about all of the other things going on at discharge – you are getting prescriptions, you are trying to find a ride home,” said Ginger McCord, MSN, RN, Director of Quality Management at Southeast Health Center. “We do an assessment as soon as possible to begin planning for what patients need to do to take care of themselves when they leave.”

The team assigns a score to each patient related to their age, gender, anticipated length of stay, acute care encounters, and emergency department visits within the last six months. A patient scoring eight or below is considered low risk for readmission, nine to 10 is moderate risk, and 11 to 12 is high risk. Those considered high risk receive a phone call 48 hours after discharge from a case manager who is a nurse. The case manager uses standardized questions that are intended to help the patient take action to avoid readmission. Patients are provided parameters to watch if they gain too much weight, and they are also given a stoplight tool to help manage their heart health.

McCord said these follow-up calls have been key in helping some of their patients avoid readmission to the hospital.

“Our case managers had found some patients who did not schedule follow-up appointments with their primary care provider while conducting their discharge follow-up call,” she said. “It’s so important that they see their doctor within 14 days of discharge, especially for those with COPD because a steroid they were prescribed here may be wearing off within that timeframe.”

McCord noted that the case manager also encountered patients who initially refused home health while in the hospital but soon realized they needed help once they were home. “Our case manager helped them set this up,” she said.

McCord said everyone at the hospital plays a role in keeping patients healthy once they step outside of the hospital.

“It’s not just case management, it’s the pharmacy and everyone else at the hospital, including the patient, who makes this work,” McCord said. “We come together as a team to bring down the mortality rate, and help our patients live a better life by teaching them about managing their chronic disease.”