Tackling Recidivism and Readmissions: Empower and Engage Your Organization

Purpose:
Define innovation in the management of ED recidivism and hospital readmissions. Outline how to engage and partner with the patient, ED staff, physicians, and post-acute providers to improve the patient experience, optimize market performance, and manage healthcare costs.

Significance:
National dilemma at hand: Can an inter-disciplinary healthcare team effectively reduce the misuse or over-utilization of the ED while ensuring continuity of high quality, patient-centered care? How do you empower & engage the patient & your organization to reduce recidivism and readmissions?

Strategy and Implementation:
Assign patient care in the right location, right setting, & right time. 1.Develop specific criteria to select appropriate candidates for care plan implementation. 2.Create operational guidelines that promote the fair and equitable treatment of all patients. 3.Identify medical personnel that would be essential in order to create a culturally-sensitive, holistic, and diverse team. 4.Gain organizational support. 5.Identify how the project can successfully incorporate actions to address the new healthcare reform measures. 6.Identify technology that facilitates communication among ED staff, and links documentation, the tracking of patient outcomes, and the gathering of data. 7.Design methods and tools to involve the patient, family, or support system in their plan of care. 8.Create partnerships with primary caregivers, pain management specialists, and external agencies to build a community of support for the patient.

Evaluation:
Since the program's inception, 210 ED care plans have been created and the first inter-state care plan was instituted last month with The University of Wisconsin. To date, results have shown 88% reduction in ED recidivism & 92% reduction in readmissions (chronic patients).

Implications for Practice:
ED over-utilization causes a drain on resources, overcrowding, an increase in costs, and an increase in wait times. Proactive care planning is an integrated & innovative care management approach that leads to reduced healthcare costs & readmission rates, while maximizing hospital reimbursement.