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Comprehensive Care Transitions Help Reduce Readmissions for Heart Attack Patients

April 03, 2018

A study of heart attack patients at Thomas Jefferson University Hospital shows that consistent discharge education and hand-off to non-hospital physicians can decrease by 48 percent the likelihood of sudden, premature return to the hospital after discharge. The research was recently published in the American Journal of Medical Quality.

The study compares outcomes and readmission rates for: 

  • 304 patients who received comprehensive, “wrap-around” care coordination as part of Jefferson’s comprehensive, multi-faceted discharge program
  • 192 patients who were enrolled in the study during the eight months before the new discharge program was implemented

Patients who participated in the wrap-around discharge program had a 30-day hospital readmission rate of 11.8 percent, compared to an 18 percent readmission rate for patients who received standard care. This reduction amounts to a 48 percent decline in the readmission rate.

The wrap-around discharge program includes many interventions designed to help patients understand the lifestyle changes and access the follow-up care needed to promote recovery. Patients in the program receive:

  • Consultation with a pharmacist, who reconciles the patient’s existing medications with new prescriptions and their potential side effects
  • Education, delivered by a nursing team, on best practices for diet, reading materials on the disease, and implications for lifestyle changes and disease management
  • If necessary, help finding a primary care physician, so that post-discharge, the patient receives regular monitoring, a plan for follow-up visits, and a check-in call in seven days 

The study shows the effectiveness of strategies similar to those used by Pennsylvania hospitals and health systems collaborating in HAP’s Hospital Engagement Network and, more recently, the Hospital Improvement Innovation Network (HIIN), to achieve reductions in 30-day all-cause readmission rates. 

Currently, 97 Pennsylvania hospitals are participating in HAP’s HIIIN, working together to further reduce readmissions by:

For more information about the HIIN and Pennsylvania hospitals’ efforts to reduce readmissions rates, contact Rob Shipp, HAP’s vice president, population health strategies. 

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