SHM Converge Scientific Abstract ePoster Gallery-Reducing 30-Day Readmission Rates: A Patient Centered Approach

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This project describes Stanford Hospital’s creation of a patient-facing Discharge Planner (DCP) to reduce readmissions and improve discharge understanding on medicine units. The problem was significant: SHC’s 30-day all-cause readmission rate was 17.3%, above the academic medical center benchmark, and hospitalist surveys suggested that 50% of readmissions were related to transitions of care gaps. Poor discharge communication also affected HCAHPS patient experience scores.<br /><br />Using a multidisciplinary, A3-based improvement approach, the team mapped discharge workflows, analyzed causes of readmission, and identified low patient involvement as a key driver. They designed a paper discharge tool that patients complete during their stay, starting at unit orientation, with review before discharge to identify and correct gaps in follow-up, PCP information, medication understanding, and other discharge needs.<br /><br />Early results from pilot units were positive. Readmissions improved by a relative 7%, and HCAHPS composite patient experience scores improved by 8% compared with stable baseline performance on non-pilot units. Among pilot patients, 42% received the DCP, and the completed forms were generally strong, with most items reaching 80% or higher completion except PCP name and follow-up appointment date, which remained weak points. Process metrics also showed progress: 47% of patients received the planner by January 2025, average completeness reached 80%, and all seven medicine units were involved.<br /><br />The authors conclude that patient involvement and comprehension are essential to high-quality discharge and readmission prevention. Future work includes collecting a full year of data, refining the tool with stakeholders, integrating social determinants of health and mental health screening, and moving toward an electronic version through the patient portal.

Asset Subtitle

Gregory S. Auda Jr.

Meta Tag

Author List Christina Miranda, Gregory S. Auda Jr., Lisa Shieh

Category Innovations

Concept Discharge Planner

Concept Discharge Quality

Concept Patient Understanding

Concept Transitional Care

Concept Medication Reconciliation

Distinguished Non-Finalist

Presenter Organization Stanford University

Presenting Author Gregory S. Auda Jr.

Track Quality Improvement

Keywords

Stanford Hospital

Discharge Planner

readmission reduction

discharge communication

patient engagement

transitions of care

HCAHPS scores

medicine units

A3 improvement

patient portal

Discharge Planner

Discharge Quality

Patient Understanding

Transitional Care

Medication Reconciliation