JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP206 – Just Hold On Were Going Home

PP206 – Just Hold On Were Going Home

The causes of readmissions occurring within 3 days after discharge or even 7 days after discharge are much more under the hospital’s control, and these near-term readmissions are preventable. Reducing 30-day readmission rate of patients discharged to home/homecare through improved follow up appointment process.  Between January 2017 and July 2017 South Pointe hospital discharged 62% of 3,404 patients to home/homecare and of those patients 15.2% were readmitted to hospital within 30 days.  Of these patients many are readmitted to the hospital soon after discharge because of their unique challenges at home or lack of an effective hand off to the community provider.
Processes implemented include: Evaluation of processes from admission to follow up appointments with the goal of promoting a smooth transition from the hospital to the home.  CM handoff to Community Care Coordinators.   Development of After Visit Summary (AVS) including follow up appointments.  Care Management Resource Center received all weekend discharges to schedule appointments.  30-day readmission rate discharges to home/home health and all cause readmissions to be measured monthly.
3 phases include:
Phase I
Process Evaluation
Cross-Continuum Team Collaboration
Phase 2
Pilot the process
Collect evaluations
Phase 3
Evaluate-Information Exchange and Shared Care Goals
Revise plan Implications for Nursing Report:
Conclusion resulted in improving the transition of care for patients discharged home/home health can be implemented in other hospitals to reduce readmissions from home/home health.

Outcomes: Readmission data collected monthly for all cause 30-day readmissions predata indicated that 13.6% of patients were readmitted, and after 8 months a decrease to 13.2%. Home predata indicated 11.9% and after 8 months of data collection showed a decrease to 9.1%. Home health predata was 14.3% and after 8 months of data collection showed a decrease of 10.4%.


1. Identify 3 phases of the evaluation process

2. Explain the purpose of decreasing avoidable 30 day hospital readmissions

3. Identify the process steps from admission to follow up appointments that promote smooth hospital to home transitions