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Medical center drops ED readmission rates, improving patient care

by Yavapai Regional Medical Center

Published on 2/7/2019

Fewer patients at Yavapai Regional Medical Center (YRMC) are returning to the emergency department (ED) within 72 hours, thanks to new alerts embedded in Cerner Millennium® solutions.

YRMC staff utilized the alerts and created reports to reduce the number of return trips by involving care teams through the Discharge Failure Risk Assessment (DFRA) program. The successful project saw the number of readmits fall from 10 percent1 to 2.7 percent.2

"There are services we provide as a not-for-profit healthcare system that we receive zero compensation for and this is the right thing for our patients and communities," said Rob Barth, RN, MSN, CEN, director of emergency services. "This initiative is a great example of this. Our ED volumes dropped significantly which is the right thing for our patients."

A Cerner ITWorks℠ associate built an icon for ED nurses that would appear if patients met the following criteria: 65 years old, admitted as an emergency patient and received hospitalization within 30 days or visited the ED within 180 days.

"If somebody met the criteria, the alert would pop up for the nurses to complete the assessment," said Carole Freeman, RN, MS, ACM, director of care management. The assessment further determines the risk of a patient returning to the ED. If the nurse selects two or more additional criteria, an order is placed for the care management team to see the patient.

A daily list of at-risk patients

The system also generates a daily list of at-risk patients, which it sends to the physician care office, the affordable care organization and the care management team. From there, teams review the list and figure ways to ensure those patients stay healthy and don’t need to return within 72 hours.

Social workers then step in and take an active role in patient care.

"My social workers look for items they can impact — mostly social determinants of health," said Freeman. "The social worker does a quick assessment to find out what the patient perceived as an issue, and what resources they might need to either maintain or improve their health and wellness."

Other patient benefits include timely filling of medications and transportation options to meet appointments with care providers. Moreover, they receive reassurance their care providers are taking proactive action to try and keep them healthy outside of the hospital.

"This also makes our discharge planning team aware of those at-risk patients who are admitted and will hopefully have the downstream effect of also reducing 30-day readmits," said Barth.

Future plans

YRMC's staff continues to look at reducing hospital readmissions to implement Readmission Prevention℠ within Cerner Acute Case Management for other health system departments.

"This will be a journey and evolution," said Diane Drexler, DNP, chief nursing officer. "It’s another tool to help us identify patients at risk for readmission, and we can be more proactive."

For more information, visit the 72 hours return page on our Model Experience website.

1 Oct. 1-Dec. 31, 2017

2 Average of 2.4 percent from Q1 2018 and 3 percent from Q2 2018

Client outcomes were achieved in respective settings and are not representative of benefits realized by all clients due to many variables, including solution scope, client capabilities and business and implementation models.