Reducing Re-Admissions from Home to a Community Hospital Using a Team Approach

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MR Cooper, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA.


This project was to reduce readmissions for patients who are discharged to home. This is an organizational project for the University Medical Center at Princeton, which is an acute facility in Plainsboro, NJ with 319 licensed beds. Faced with pay for performance program payment reductions, a multidisciplinary steering committee was formed to develop a readmission reduction program. Through the use of evidence based guidelines and tools, the committee has base-lined the organization maturity in its readmission reduction efforts, and found opportunities for improvement related to the identification of at-risk patients, medication reconciliation, post-discharge follow-up calls and end of life care planning. Focus groups have been formed to address these findings, and are early in the action plan phase of the program.

Presentation: 45:45

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