Small and Rural

Jersey Community Hospital, Jerseyville
Reducing All-Cause Readmissions by Improving Coordination Across the Care Continuum

With baseline data from the Centers for Medicare & Medicaid Services (CMS) showing an all-cause readmission rate of 16% and a CMS Star Quality Rating of 3, a project team set out to decrease the all-cause readmissions rate to below 10% and to increase our CMS Star Quality Rating to 4. Using Lean Six Sigma methodologies, the team formulated a multi-faceted improvement plan, which included post-acute care partners, home health agencies and skilled nursing facilities.

Readmission reduction strategies included the development of a hospitalist team and improvements in:

  • Coordination with post-acute care agencies;
  • Multidisciplinary rounding;
  • Discharge planning; and
  • Patient follow-up protocols.

As a result, the all-cause readmission rate dropped from 16% to 7% with an estimated 63 readmissions prevented over a 12-month period and a total cost savings of $455,600.