Background and Purpose: Hospital readmissions have become a priority focus for healthcare organizations. According to the Centers for Medicare and Medicaid, 20% of all patients who are discharged from a hospital will be readmitted within thirty days (CMS, 2015). This not only has a negative impact for the patient, but also imposes a financial impact on the healthcare organization. Baseline data from 2014 at Lake Cumberland Regional Hospital (LCRH) showed a stroke readmission rate of 9.6%. The purpose was to decrease stroke readmissions through development of a discharge call process that targets risk factors for readmission and ensures transition from hospital care to post-discharge follow-up.
Methods: The discharge call process was implemented in June 2014. Calls were conducted by the facility’s stroke educator. All stroke program participants excluding discharges to nursing homes, rehabilitation center, or hospice were included in the discharge call process. Minimally, 3 attempts per patient were made to conduct the phone call within 3 days of discharge. In addition, the Lake Cumberland Area Stroke Support Group was established in May 2016 for stroke survivors and their caregivers.
Results: Stroke readmission rates at LCRH decreased to 7.9% in 2015 and further declined to 1.6% as of 2nd quarter 2016. Interventions completed as a result of the discharge phone call process include: expediting follow-up appointments, collaborating with primary care practitioner for needed prescriptions, clarifying discharge instructions, reinforcing stroke education, and scheduling additional follow-up calls to provide assistance when needed.
Conclusions: Stroke readmission rates decreased from 9.6% in 2014 to 1.6% through second quarter of 2016. Multiple opportunities were discovered to close the communication gap between hospital care and primary care follow-up. Maintaining contact post-discharge is needed to transition from the hospital to home care.