Hospitals in pursuit of excellence

Care Coordination Across the Continuum to Improve Transitions of Care with the Goal of Reducing Readmissions

The hospital started working on Project Re-engineered Discharge (Project RED) in 2011. A patient navigator was hired to focus on Medicare patients with congestive heart failure. In 2013, the roles were realigned and the navigator, utilization manager and social worker started reporting directly to chief nursing officer, the project leader for this initiative. The hospital participated in the bridge cohort with IHA in 2013-2014. An interdisciplinary team of physicians and front-line staff presented the new discharge planning design to senior leaders and medical staff. Frontline staff identified the area of opportunity in the care continuum between the hospital discharges until 30 days. A sub-team was created to look into the transitional care of the patient. The team meeting was restructured to include all care team members and a template to guide the patient plan of care was developed. The team meets Monday-Friday. The transitional care management team identified that readmissions among the long-term care facility population were high. Another team was formed with representatives from local long-term care facilities and identified that hand offs and cross-organizational communication were problematic. Processes are continuing to be streamlined, utilizing the PDSA model for improvement.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state.  These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)