By Joseph Burke, RN, MPH – Senior Consultant at HCIT Consulting



This inner city, academic, teaching and tertiary referral hospital provides care for very complex patients both medically and socioeconomically within a large metropolitan area and beyond. Transitioning patients from the acute phase of medical care to the next appropriate level of care and site to ensure continuity of care with optimal clinical outcomes is very challenging. Over the last two years, work has been done to improve the efficiency and effectiveness of the hospital discharge process. That work included the building of relationships, improving clinical information transfer, and setting common goals with post-acute community providers including physicians, federally qualified health centers, skilled nursing homes, home health agencies, and hospices. Although the patient transitioning processes has improved, there has not been an acceptable reduction in avoidable readmissions. To further reduce avoidable readmissions a multi-disciplinary team was formed. That team completed a GAP analysis of best practices and defined and have implemented with action items defined for implementation.


Due to the focus by CMS-Medicare by public reporting and potential penalties for excessive and avoidable readmissions, as well as the general need to ensure efficient and safe patient transitions for all patients, the hospital chose to improve transitions of care processes by reducing avoidable readmissions.


  1. Reduce % All Cause All Payer AMI Readmissions by 20%, (R=14.8%)
  2. Reduce All Cause All Payer HF Readmissions by 10% (R=24.2%)
  3. Reduce All Cause All Payer PN Readmissions by 10% (R=17.3%)


(A) The following “team” structured were put into place to gain knowledge assess needs and implement change:

  • Steering Committee
  • Operational Team Meeting (weekly)
  • External Collaboration HA-Hospital Engagement Network
  • UHC-Best Practices for Better Care

(B) The Steering Committee completed a GAP analysis of best practices and determined eight key areas for focused attention with a focus on patients who are high risk for readmission.

(C) The eight key areas from the GAP analysis and status follow:

  1. Transition Coordination Program-Implemented
  2. EPIC-Readmission Risk Assessment-Implemented
  3. EPIC-Transition Coordination Design-Implemented
  4. Teach-back Skills-Implemented
  5. Palliative Care Services Edu/Activity-Implemented
  6. Readiness for Discharge-Pilot 1-21-13
  7. Transition to/from Post-Acute Facilities-Actions Items Defined
  8. Hospital Appointment Setting Standards-Defining Capacity


Pre-Consulting & Post-Consulting Comparison
Balanced Scorecard Pre 12 month Post Change % Change
Composite Actual 19.8% 15.6% -4.2% -21.2%
CHF Actual 24.2% 17.2% -7.0% -28.9%
AMI Actual 14.8% 12.9% -1.9% -12.8%
PN Actual 17.3% 15.3% -2.0% -11.6%



The results of this initiative  include:

  1. Goals met and reduction in avoidable hospital readmissions for  HF, AMI and PN patients.
  2. Improved transition processes from acute care to post discharge sites/locations benefiting all patients.
  3. Completed key action items defined in GAP analysis to ensure reliability of processes.


Joe Burke, RN, MPH (Senior HCIT Consultant), Chief Medical Officer, Chief Nursing Officer, Internal Medicine Attending Physician, Gerontology Attending Physician, Emergency Medicine Attending Physician, Physician Practice Quality Director, Internal  Medicine Resident, Social Work Manager,  Outreach Manager, Pharmacy Director, Surgical Resident, Case Management Manager, Internal Medicine Nursing Director, Skilled Nursing Representative, Home Health Representative, Federal Qualified Health Center Representative,  Cardiology Nurse Practitioner, Palliative Care Advanced Practice Nurse.