A multipronged strategy involving early identification of high-risk patients, education and coordination helped Jersey City (N.J.) Medical Center reduce its congestive heart failure readmission rate by 30 percent from 2008 to 2010. Joseph Scott, president and CEO of Jersey City Medical Center, shares the hospital's interventions.
1. Early identification of high-risk patients. One strategy was to identify patients at risk for readmission early and intervene to prevent a readmission. Hospital staff identified high-risk patients by certain clinical factors, data from patients' previous visits and their insurance status. For example, patients that had previously been readmitted within 30 days of discharge were identified and connected with a patient navigator to help prevent another readmission.
2. Outreach by patient navigators. Patient navigators played an integral role in the readmission prevention initiative at JCMC. The navigators communicated with patients throughout their stay and educated them about what to do to stay healthy after discharge. The navigators also monitored patients' health after discharge. For example, if a patient gained three pounds in one day, the navigator would contact the physician to intervene, as weight gain is a risk factor for heart failure patients.
3. Patient education. Educating patients about their condition and instructions post discharge was an important readmission prevention strategy. JCMC educated patients at high risk for readmission on appropriate responses to real-life scenarios. For instance, congestive heart failure patients learned to understand the salt content of food, as an excess of salt poses a risk of heart failure, as well as the importance of taking one's weight daily. Furthermore, the hospital worked with post-acute care providers to develop a simple education guide for patients as they transitioned from the hospital to the post-acute care provider or home. "It has had a significant impact on educating patients as they moved," Mr. Scott says.
4. Coordination with post-acute care providers. In addition to developing the education guide in collaboration with post-acute care providers, JCMC worked with these providers to coordinate the care of patients as they transition out of the hospital. Hospital leaders raised awareness among post-acute care providers, such as nursing homes and home health agencies, about the risk factors for readmission among heart failure patients and prevention strategies. "Being successful in the future is going to be about how we coordinate care across the continuum, so we've been proactive in trying to do that as much as possible," Mr. Scott says.
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