PP113 – The Impact of Patient Engagement and Social Determinants on Reducing Readmissions
One of the primary goals of the Sharp Rees-Stealy Population Health Department is to reduce avoidable readmissions. Reducing readmissions produces quality patient outcomes, optimal patient engagement and reduces total cost of care across the healthcare system. In 2018 the Readmission Review Committee was established to help address patient care opportunities, to discuss admission trends and outcomes and develop processes to reduce readmissions of our Senior HMO Population. Data revealed in 2018 the overall readmission rate was 20.4%, of which 13.1% patients were readmitted while not engaged in our programs versus 7.3% were readmitted while in our programs. This resulted in an average 21% less readmissions for patients engaged in a case management program with us. The department embraced and organized efforts to develop efficient processes for patient centered care to impact outcomes and decrease readmissions, more than meeting expectations to become a model of Best Practice. This committee’s efforts have been successful to identify practice gaps, increase patient engagement, analyze impact of social determinants and advance care planning on readmissions and the opportunities for improvement. The readmission rates of patients engaged in programs continues to be markedly lower than patients that are not engaged in our programs. The success of this committee is just one component of our multifaceted Population Health department structure that has contributed to improving quality care of seniors in the greater San Diego community.