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Reducing Readmissions through Coordination, Communication

Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), San Francisco’s only essential hospital, has a diverse patient population at high risk of readmissions. On average, 8 percent to 10 percent of admitted patients are marginally housed or homeless. According to the ZSFG annual report (fiscal year 2012-2013), about 30 percent of patients are uninsured, 40 percent are on Medicaid, and 20 percent are on Medicare. Nine percent of patients are older than 65.

ZSFG leadership recognized an opportunity to lead the way in developing a comprehensive, systems-based care transitions program that would provide patients with the proper care and the tools they need to stay out of the hospital. The ZSFG Care Transitions Taskforce was chartered for this purpose in October 2012. The Taskforce grew through grassroots relationship-building into an organized, multidisciplinary working group comprising inpatient and outpatient providers. They set a collective goal to reduce readmissions by 15 percent and standardize processes of care. The Taskforce served as a central organizing platform to support pilots of new, formal care transitions initiatives, disseminate projects throughout the network of providers in the continuum, and partner with initiatives that include, but are not limited to, the San Francisco Health Network.

One such initiative is the Centers for Medicare & Medicaid Services-funded San Francisco Community Care Transitions Project (SFCCTP). The SFCCTP is a coalition of eight hospitals, nine community-based organizations, and the San Francisco Department of Aging & Adult Services that works to bridge the gap between hospital discharge and strong recovery. For up to six weeks post-discharge, social workers provide coaching, care coordination, and services previously unavailable to elderly and disabled patients.

The Care Transitions Taskforce has successfully minimized duplication of services and enabled more effective communication between providers to optimize efficiency and improve patient outcomes. The Taskforce has also invested in streamlining access to medical information by creating a robust data dashboard that allows inpatient and outpatient care teams to receive timely and meaningful feedback about readmissions and process measures of care transitions. It also has worked on improving identification of patients who will most benefit from transition interventions.

In the fall of 2012, the ZSFG Transitional Care Nursing Program was implemented to foster safer transitions from the hospital to the community and to prevent readmissions among high-risk patients (those 55 or older and with core measure diagnoses). This nursing-based intervention incorporates motivational interviewing, bedside teaching and coaching, expanded medication reconciliation, a personalized discharge plan, and post discharge phone calls for 30 days. The program now averages a 30-day, all-cause readmission rate of 10 percent.

Critical Components

Leadership involvement is critical to facilitating culture change and sustaining successful programs. Despite limited resources, the Taskforce has increased its membership (more than 30 active contributors), gained executive sponsorship, and enhanced health information technology.

Relationship building within the community is essential for the sustainability of the program. The partnerships between ZSFG and key community stakeholders have promoted improvements in coordinated care delivery, increased access to medical information, and enhanced care transitions from hospital to home.

Originally published July 11, 2014


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