SHM Converge Scientific Abstract ePoster Gallery-Comprehensive Interdisciplinary Readmission Reviews Associated With Improved Outcomes

Pdf Summary

Northwell Health describes a broad commitment to improving community health through high-quality clinical care, medical education, research, health promotion, and care for all patients regardless of ability to pay. As New York State’s largest health care provider and private employer, it operates 23 hospitals and more than 700 outpatient sites, with a large network of affiliated physicians.<br /><br />The document then presents a quality-improvement project from North Shore University Hospital on reducing Medicare 30-day readmissions. Since CMS readmission rates affect hospital quality ratings, the hospital created an interdisciplinary review process in 2019 to better understand unplanned readmissions and improve transitions of care. The goal was to identify discipline-specific gaps, strengthen communication between inpatient and outpatient teams, and increase accountability for the primary care team.<br /><br />The review process focuses on Medicare fee-for-service patients who return to the ED within 30 days of discharge. Weekly remote meetings bring together inpatient and outpatient leaders, physician advisors, transitional care staff, primary care physicians, specialists, nursing, care coordination, hospice, home care, and quality management. Each case is summarized and discussed in about 20 minutes, with the discharging attending presenting the case and identifying opportunities for improvement.<br /><br />Commonly discussed topics include inpatient management, discharge appropriateness, adherence to evidence-based guidelines, goals-of-care conversations, communication issues, ED management, and outpatient follow-up access. Interventions often include community partner involvement, earlier goals-of-care discussions, hospice evaluation, house calls referrals, and better interdisciplinary communication.<br /><br />The process has been well received and is credited with improved Medicare readmission rates overall, including CHF and pneumonia cohorts. It has also been adopted as a best practice at other Northwell sites. Future plans include reviewing high-risk patients earlier during hospitalization and addressing high-utilization and long-stay cases to improve excess days in acute care measures.

Asset Subtitle

Charles L. Kast

Meta Tag

Author List Andrea Restifo, Charles L. Kast, David Hirschwerk, Jonathan Silver, Katherine Soel, Michael Gitman, Yakov Kandov

Category Innovations

Concept CMS 30-Day Readmission Rate

Concept Transitional Care

Concept Multidisciplinary Collaboration

Concept Readmission

Concept Interdisciplinary Readmission Review

Distinguished Non-Finalist

Presenter Organization North Shore University Hospital, Northwell Health

Presenting Author Charles L. Kast

Track Transitions of Care

Keywords

Northwell Health

community health

quality improvement

Medicare readmissions

North Shore University Hospital

transitions of care

interdisciplinary review

hospital readmission reduction

care coordination

patient outcomes

CMS 30-Day Readmission Rate

Transitional Care

Multidisciplinary Collaboration

Readmission

Interdisciplinary Readmission Review