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Ty Cobb Regional Medical Center Reducing Readmissions. DEFINE. Scope – Decrease 30 day readmission rate by 20% Project charter completed and approved Team members: Nursing, Case Management, Utilization Review.

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  • Scope – Decrease 30 day readmission rate by


  • Project charter completed and approved
  • Team members: Nursing, Case Management,

Utilization Review

  • Line chart, Histogram, Xbar and R chart data reviewed by team members
  • Process in control but not what we wanted
  • Process Flow Mapping discussed
  • Map completed
  • “Sticky note” brainstorming
  • Process map was separated into sections:

Admission, Inpatient Care, Day of Discharge and Post Discharge

  • Each member moved from chart to chart
  • 52 thoughts added to flow map
  • Developed a list of improvement priorities
sticky note exercise
Sticky note exercise

Different map sections were placed around the room. Each team member was given a pen and a sticky note pad. They had 5 minutes to spend at each station writing as many suggestions or concerns as they could.

improve implement
  • A problem list was developed and prioritized
  • Specific task list was made
  • Department involvement for each task was delineated using RASCIN chart
task list
Task List
  • Combine Readmission Risk Assessment and Case Management Assessment
  • Provide in-service to Nursing staff on patient education techniques and use of “Teach-Back” method
  • Create e-forms for documentation
  • Concentrate post-discharge calls on “high risk” patients
  • Better utilization of Home Health Care
readmission risk assessment
Readmission Risk Assessment
  • A “home needs” screening is completed on each patient on admission
  • Any positive screen is referred to Case Management and an in-depth assessment is performed
  • We simply added questions to that assessment that will determine risk of readmission
  • High risk patients receive a detailed post discharge call
teach back
Teach Back
  • Teach back is a method of education assessment that requires the patient to repeat back the instructions in their own words
  • If the patient’s description differs from what was taught, re-education can occur at that time
post discharge calls
Post Discharge Calls
  • Post discharge calls are completed by Utilization Review staff a few days after patient discharge.
  • Patients are contacted at home to see how they are progressing and to discuss medications, follow up appointments
  • Any problems noted are sent to Case Management for resolution
home health care
Home Health Care
  • Our overall goal is for each high risk patient to be evaluated for Home Health Care and to be referred if they could benefit from services
home health benefits
Home Health Benefits
  • Reinforcement of hospital discharge information
  • Periodic physical assessments to prevent disease from progressing to hospitalization level
  • Patients can remain at home in familiar surroundings and still receive the care they need
  • 30 day Readmission Rate dropped from 0.0352 to 0.0128
  • Decrease of 63.6%
  • Projected Financial loss prevention:


  • Continue to evaluate control charts
  • Policy development to standardize the discharge process
thank you
Thank you!!

Tina Thomas RN

Ty Cobb Regional Medical Center

Lavonia, Georgia