Reducing Hospital 30-Day Readmissions Through a

Community Care Coordination Collaborative

Myron Soyangco, Lean Six Sigma Black Belt
Tametha Stroh, RN, MSN, CPPS, CPHRM
FORMATION OF THE COLLABORATIVE STRUCTURE OF THE COLLABORATIVE
The community collaborative aims to decrease the number of patients readmitting to Sharp MEETING FREQUENCY:
Grossmont Hospital (SGH) from post-acute care facilities (Skilled Nursing Facilities, Long-Term Acute The team meets quarterly to discuss opportunities for improvement, product/process design, and
Care Facilities, Home Health Agencies, etc.) within 30 days of hospital discharge. From Post-Acute Facilities To Post-Acute Facilities
ongoing feedback of performance improvement work. During the months between the quarterly
sessions, the SGH Core Workgroup meets to create viable work products and in-hospital processes,
THE NEED ADDRESSED: further define identified issues through the hospital’s context, and perform novel data analysis.
 Patients readmitting after being discharged to post-acute care facilities account for 36% of SGH Presentation of Ideas, Workouts and Communication is cyclical with closed loop communication of ongoing PI work and outcomes.
Data, or Work Products Table Top Exercises
30-day readmissions, based on 2016 data
 Improve patient care processes and outcomes throughout continuum of care with person-centered LAUNCHING THE COLLABORATIVE:
care philosophy Community Collaborative A 3-meeting agenda was created specifically for launching the care coordination collaborative, that
SGH Core Workgroup
 After years of consistent improvement though the creation of disease-specific clinical excellence focused on building community relationships, communicating a shared vision, and establishing
teams targeting in-hospital processes, hospital readmission rates plateaued at around 16% foundations for PI. Initial meetings consisted of the following three critical factors to success:
 Introduction and learning about each other’s accomplishments and challenges
Work Product Creation Synthesis of Ideas
FORMULATION, CHARTER, and STRATEGIC FOCUS:  Needs assessment, identification of opportunities for improvement, and prioritization of actions
 Chartered in collaboration with the Health Services Advisory Group (HSAG) and east San Diego  Data analysis of historical quality metrics
County facilities and care agencies
 Focused on learning, transparency, and performance improvement (PI) work, through the Lean Six Hospital Pilots Hospital Data SITE VISITS AND CONSULTATION:
Sigma (LSS) methodology and facilitated by a certified LSS Black Belt COLLABORATIVE COMMUNICATION AND PI WORKFLOW As a core component of the community approach, each community partner was invited to
participate in site-visits and personalized consultative work with the hospital’s performance
PARTICIPANTS improvement specialist and/or directors of quality and case management. These visits aim to
 Over 90 attending members including: increase community connections, improve information exchange between sites, and promote
collaborative PI work. Each site visit follows a standardized template of information sharing, idea
 Hospital Representatives (Quality, Case Management, Disease Experts, Pharmacy, Nursing, Care
solicitation, data interpretation, and PI performance review.
Transitions, Physicians, Administrators, Advanced Illness Management, Information Systems)
 Top 10 readmitting facilities for Skilled Nursing, Post-Acute, and Long Term Care ,Home Health
For questions or requests for more information, contact the leaders of this project at:
Agencies and Family Health Clinics (over 30 community partners) Myron.Soyangco@sharp.com
Tametha.Stroh@sharp.com

COMMUNITY COLLABORATIVE INTERVENTIONS AND OUTCOMES

INTERVENTION 1: REFERRAL AND INTAKE TRANSFER FORM STREAMLINING INTERVENTION 2: PATIENT “WHAT TO EXPECT” BOOKLET
Patient Readmissions to a Sharp Hospital within 30 days of discharge, 2E/5E
source: PEAK
20%
intervention 1: transfer information streamlining
 Created a patient/family booklet to guide patients through
pilot period
18%
continuum of care post hospital discharge
16%

14%
 Includes education and worksheets focusing on:
12%  Appropriate facility selection
10%
 Expectations on post-acute preparation, services, staffing,
8%
physician coverage
6%

4%  Frequently Asked Questions

2%
 Hospital-wide pilot began on August 1, 2018
0%
January '18 February '18 March '18 April '18 May '18 June '18 July '18

 Improved patient-to-post-acute care facility referral process to reduce “false acceptances” that
result in last-minute patient rejection and immediate return to hospital by:
Reducing referral packet and document attaché from upwards of 60-100 pages to 20 pages

 Creating algorithmic “go/no-go” decision points of pertinent patient information (e.g.,
“tracheostomy care needed”, which is an automatic disqualifier for certain facilities)
 Improved patient-to-post-acute care facility transfer process to improve immediate provision of
care upon admission to a post-acute facility to minimize immediate return to hospital by:
 Reducing transfer packet and document attaché from an average of 40 pages to 20 pages
 Emphasizing immediate care needs within the first 3 hours of care such as dietary needs, pain
management, antibiotics, etc. through optimized information handoffs
FUTURE AREAS OF FOCUS
Intervention 1: Referral and Intake Transfer Form Streamlining piloted on Med/
 Enterprise spread of care coordination collaborative structure at sister sites and their immediate
Oncology (2E) and Post-stroke (5E) progressive care units in hospital, over four
months covering > 200 patients. community partners
Pilot shows a decrease in readmissions within 30 days of discharge from  Develop key strategies with community partners to standardize work for consistent
approximately 13.5% to < 8% in July 2018. management of Advanced Illness Management and Palliative care
 Strengthen sustainability of patient support through all steps of the continuum of care
 Analyze opportunities for improvement following patient discharge from post acute facility to
home (with or without home health assistance) to avoid readmission
In partnership with Strengthen community networking with county resources
