SHM Converge Scientific Abstract ePoster Gallery-Collaborative and Interdisciplinary Approach to Readmission Reduction

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This document describes Northwell Health’s collaborative, interdisciplinary effort to reduce hospital readmissions among high-risk CMS STAR patients, especially those with CHF, COPD, pneumonia, and acute myocardial infarction. Because readmission reduction accounts for 22% of the hospital’s STAR rating, the organization created a shared responsibility model to improve workflow, balance workload, and deliver more consistent care.<br /><br />A daily “STAR CHASE” list is generated and sent to case management, hospitalists, emergency medicine, pulmonology, cardiology, social work, and outpatient navigation teams. Each discipline has a defined role. Hospitalists or advanced care practitioners discuss advance care planning, case management arranges a follow-up visit within seven days and coordinates home care, and outpatient navigators ensure the patient is monitored after discharge in the community.<br /><br />If a patient returns to the emergency department, the hospitalist team initiates the SWAT process, working with emergency medicine providers day or night. The patient is then reviewed by emergency physicians, hospitalists, consultants, case management, and outpatient navigation with the goal of safely managing the patient in the ED and avoiding unnecessary admission when possible.<br /><br />The project emphasizes that collaboration across inpatient, outpatient, and transitional care teams improves patient safety, standardizes care, and supports better outcomes. The reported readmission rate decreased from 18.6% in 2019 before the collaboration to 14.1% in 2022, suggesting the model was effective in reducing readmissions.

Asset Subtitle

Sadia Arshad

Meta Tag

Author List Corinne Aylward, Jean Shelton, Lindsey Frank, Sadia Arshad, Sanjeev Sharma, Sunil Shah, Tajammul Shah, Valerie Kruszon

Category Innovations

Concept Hospital Readmission

Concept High-Risk Patient

Concept Interdisciplinary Team

Concept Care Transition

Concept Emergency Department Return

Distinguished Non-Finalist

Presenter Organization Northwell South Shore University Hospital

Presenting Author Sadia Arshad

Track Transitions of Care

Keywords

hospital readmissions

Northwell Health

STAR patients

care coordination

case management

transitional care

emergency department

CHF COPD pneumonia myocardial infarction

collaborative workflow

readmission reduction

Hospital Readmission

High-Risk Patient

Interdisciplinary Team

Care Transition

Emergency Department Return