This is my slide deck for a webinar August 23rd at 1:00 PM Eastern Daylight Time (see information below). This highlights SETMA’s work on preventable readmissions and our on-going effort to reduce re-hospitalizations. Our work incorporates a number of the recommendations or the Institute for Healthcare Improvement (IHI). The following is a copy of a “Thought Leaders” comment” which is published in the ReAdmissions News this month
“Few challenges to healthcare are as complex as is the effective reducing of re-hospitalizations and few challenges demonstrate the absence of collaboration and coordination between the various constituencies in healthcare delivery as does re-hospitalization. In SETMA's experience two metrics significantly impact re-admission rates: "did the patient receive a car- coaching telephone call within 24 hours of discharge" and "was the patient seen by the primary care health home within 3-6 days of discharge."
“The hospital cannot make either of these happen without a collaborative effort and/or a coordinated effort with the primary care attending physician. As long as the hospital emergency department is seen as the most effective safety net by patients and their families, and/or as long as there is not effective communication and access between the primary care provider and the patient, preventable re-hospitalizations will continue to take place.
“No patient should leave the hospital without an assessment of their risk of re-hospitalization having been made and, if the patient is high risk, without an action plan being executed to meet the patient's needs to prevent re-hospitalization. The hospital may need to serve as the convener of dialogue between primary care, consumers, emergency department staff, home care agencies, social service agencies, and hospital staff members to improve care transitions and communications so that patients' default position is not "let's just go back to the hospital." James L. Holly, MD
Few challenges to healthcare are as complex as is the effective reducing of re-hospitalizations and few challenges demonstrate the absence of collaboration and coordination between the various constituencies in healthcare delivery as does re-hospitalization. In SETMA's experience two metrics significantly impact re-admission rates: "did the patient receive a care coaching telephone call within 24 hours of discharge" and "was the patient seen by the primary care health home within 3-6 days of discharge",
The hospital cannot make either of these happen without a collaborative effort and/or a coordinated effort with the primary care attending physician. As long as the hospital emergency department is seen as the most effective safety net by patients and their families, and/or as long as there is not effective communication and access between the primary care provider and the patient, preventable re-hospitalizations will continue to take place.
No patient should leave the hospital without an assessment of their risk of re-hospitalization having been made and, if the patient is high risk, without an action plan being executed to meet the patient's needs to prevent re-hospitalization. The hospital may need to serve as the convener of dialogue between primary care, consumers, emergency department staff, home care agencies, social service agencies, and hospital staff members to improve care transitions and communications so that patients' default position is not "let's just go back to the hospital." | 
