Home / Degree Programs / Academic Units / School for the Science of Health Care Delivery / Student Research / Readmission Prevention: A Case-Study Analysis of an Urban Transitional Care Clinic

Readmission Prevention: A Case-Study Analysis of an Urban Transitional Care Clinic

Research Domain: 
Population Health
Systems Engineering
Community Partner: 
Dignity Health
Student Researchers: 
Matthew Speer and Joe Brinkman
Faculty Mentor: 
Mac McCullough

In recent years, widespread and intense efforts to reduce excess hospital readmissions have been spurred by heightened awareness of the prevalence of readmission as well as new financial penalties linked to readmission rates. Studies have reported that approximately 20 percent of Medicare beneficiaries discharged from hospitals were re-hospitalized within thirty days and that 34 percent were readmitted within ninety days. Nearly 13 percent of Medicare beneficiaries discharged from hospitals experienced three or more provider transfers during a thirty-day period. This movement of patients from hospitals to the community and back again accounts for an estimated $15 billion in annual Medicare spending. To interrupt patterns of frequent use of health care services among the chronically ill and to address the negative effects on quality and costs, innovative solutions aimed at improving integration and continuity across episodes of care have emerged. Collectively, these solutions are referred to as “transitional care.” Objective/Problem: Statement: Dignity Health has established their own center for transition care, henceforth referred to as CTC, at their St. Joseph’s Hospital campus in downtown Phoenix. Having seen their first patients in December of 2015, 82 had been followed in total by the CTC by April 2016. Of this group, 5 had been readmitted to a Dignity Health facility within 30 days of their visit to the clinic. The goal of this project involves a thorough retrospective analysis of these patients in order to determine what factors might have prevented their admission.

Electronic health records of five readmitted patients will be systematically reviewed and synthesized at length in order to identify any potential underlying causalities attributing to their readmission. These reviews will be performed using both Cerner and Allscripts records for the patient through the Dignity Health network.

Extrapolation of pertinent data through chart reviews and CTC provider interviews for all five patients were performed successfully. Conclusions: After a detailed investigation of the aforementioned medical records, it was determined that staff at the CTC weren’t notified of their patients’ readmissions, and thus a trigger mechanism, conceivably within the EMR, informing the clinic of these circumstances would be advantageous. Also made apparent was the lack of patient prioritization for follow-ups with outside facilities/specialists. Causality for these complications was discussed with providers and staff at the CTC, at which point plans to implement quality improvement measures has begun.