SHM Converge Scientific Abstract ePoster Gallery-Improving Health Care Transitions to Reduce Cardiorespiratory Readmissions

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This project aimed to reduce 30-day hospital readmissions in the cardiorespiratory cohort at the Louis Stokes Cleveland VA Medical Center from a baseline of 14.55% in Q4 FY2021 to 12% by Q4 FY2022.<br /><br />A Gemba walk was completed in Q2 FY2022, with stakeholder interviews from inpatient and outpatient teams to identify root causes of readmissions. Key problems included weak caregiver engagement during bedside rounds, inadequate post-discharge medication reconciliation, and insufficient patient-centered communication.<br /><br />A three-part intervention was implemented:<br />1. Home Based Primary Care (HBPC) outreach for patients with CAN scores above 90, including home visits within 5 days of discharge for medication review and disease-specific education.<br />2. Use of whiteboards to document the inpatient plan of care.<br />3. Involvement of caregivers in bedside rounds.<br /><br />Results showed mixed process improvement. HBPC consults rose by 50% initially but returned to baseline by the end of the quarter. Fewer than 10% of caregivers attended bedside rounds, and plans of care were written on whiteboards for 67% and 22% of patients on the two intervention teams.<br /><br />Despite limited improvement in process measures, readmissions fell from 14.55% to 12.49% after implementation, reached a low of 10.9% in Q3 FY2022 with special cause variation, and ended at 12.43% in Q4 FY2022. The project did not fully meet its target, but it still reduced readmissions overall by about 2% and was associated with estimated net savings of over $300,000. The authors note that increased awareness after the Gemba walk may have contributed to the improvement, but more data are needed to assess sustainment.

Asset Subtitle

Paul M. Shaniuk

Meta Tag

Author List Andrew T. Harris, Anton M. Vehovec, Deanna White, Jeffrey Sedlak, Kimberly L. Cunningham, Melissa Klein, Mia Wade, Paul M. Shaniuk, Sebastian Godbey, Todd I. Smith

Category Innovations

Concept 30-Day Readmission

Concept Readmission Rate

Concept Cardiorespiratory Cohort

Concept Quality Improvement

Concept Root Cause Analysis

Distinguished Non-Finalist

Presenter Organization VA Northeast Ohio Healthcare System

Presenting Author Paul M. Shaniuk

Track Transitions of Care

Keywords

30-day readmissions

cardiorespiratory cohort

hospital readmission reduction

Gemba walk

caregiver engagement

medication reconciliation

patient-centered communication

Home Based Primary Care

whiteboard care plans

VA Medical Center

30-Day Readmission

Readmission Rate

Cardiorespiratory Cohort

Quality Improvement

Root Cause Analysis