When patients reach the end of their hospital stays, Hattiesburg Clinic nurses stay on the line to monitor their continuing progress and proactively identify issues that might lead to readmission. Two years after beginning their transitional care management program, Hattiesburg Clinic’s nurses have made over 7,000 follow-up calls, and readmission rates have decreased by 14%.
Using dashboards in Epic, nurses identify which patients are a good fit for the program. If a patient is still admitted, a nurse can drop by for an in-person introduction and describe what to expect from the program. For recently discharged patients, nurses schedule a call to check in.
Patients who are identified as high-risk for readmission based on a predictive algorithm in Epic are contacted weekly, and nurses monitor them using Epic for 30 days after discharge. Because Hattiesburg discovered that most patient readmissions happened between 25 and 30 days post-discharge, nurses contact all patients 25 days after discharge, even if they’re at a lower risk for readmission and aren’t enrolled in the weekly follow-up program.
In more than 4,500 cases, well-timed care manager check-ins prompted visits with patients’ PCPs, preventing concerns from becoming serious enough to warrant readmission.
Hattiesburg Clinics achieved HIMSS Stage 7 recognition in 2015 for successes including their transitional care management program.