LCMC has a data-driven project that has dramatically reduced hospital readmissions among Medicare patients. The hospital identified a need to reduce admission rates through their review of regulatory and health improvement organization literature on readmissions, their strategic goals, readmission data, and risk stratification. As part of the project, teams took a deep dive into the drivers of high utilization and adjusted programs to better serve patients.

One of the primary approaches to improving care coordination and reducing hospital readmissions was increasing the presence of case management in the emergency department (ED). Case managers regularly meet with the patients and their families in the ED to take a holistic approach as to why they are in the hospital or perhaps have returned to the hospital. The hospital also implemented a new patient and family questionnaire that was given to patients who have been in the hospital multiple times throughout the year. This questionnaire was modified to gain a better perspective of why the patient and his/her family members believed they were back in the hospital. Lastly, the third major approach to support care coordination and reduce hospital readmissions was the implementation of home visits by emergency medical services (EMS). The hospital developed a process for EMS to visit the patients once they transitioned home.