SHM Converge Scientific Abstract ePoster Gallery-The Readmission Reset: How a Coordinated Protocol Cut Readmissions by 75%

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This document describes a hospital-wide, hospitalist-led readmission reduction initiative aimed at CMS “Star” patients with high-risk diagnoses such as pneumonia, AMI, COPD, and CHF. The problem began with a sharp rise in targeted 30-day readmissions from 9% in 2023 to 16% in 2024, highlighting gaps in transitions of care and discharge planning.<br /><br />To address this, the hospital implemented a standardized interdisciplinary rounds (IDR) transitions protocol. The protocol uses a daily checklist to identify patients early, secure a 7-day post-discharge appointment, assess social determinants of health and caregiver needs, complete goals-of-care discussions, ensure 30-day medications and meds-to-beds, arrange PCP/SNF warm handoffs, and complete 72-hour follow-up calls. Responsibilities are shared across hospitalists, nursing, case management, social work, pharmacy, palliative care, quality, and other teams.<br /><br />Unresolved issues are escalated during IDRs to the hospitalist, and persistent barriers are elevated to physician leadership before discharge. This creates a coordinated pathway to address clinical, social, and logistical obstacles that could lead to avoidable ED returns or readmissions.<br /><br />Results showed a 75% reduction in avoidable 30-day readmissions when comparing equivalent 8-month periods (January–August) for targeted patients. The authors conclude that the model is reliable, scalable, and aligned with CMS value-based care goals. It improves continuity, operational efficiency, patient satisfaction, and safety while offering a framework that can be adapted across other hospitals and health systems.

Asset Subtitle

Saumya Sharma

Meta Tag

Author List Danielle Rosemond, Saumya Sharma, Scott Bodner

Category Innovations

Concept Transitional Care

Concept Readmission

Concept Interdisciplinary Rounds

Concept Discharge Planning

Concept Continuity of Care

Distinguished Non-Finalist

Presenter Organization Northwell Health

Presenting Author Saumya Sharma

Track Quality Improvement

Keywords

readmission reduction

hospitalist-led initiative

CMS Star patients

interdisciplinary rounds

transitions of care

discharge planning

30-day readmissions

meds-to-beds

care coordination

value-based care

Transitional Care

Readmission

Interdisciplinary Rounds

Discharge Planning

Continuity of Care