Reducing Readmissions Using Collaborative Care.

Purpose of initiative: After noting an elevated chronic obstructive pulmonary disease readmission rate for 2022, the inpatient Nurse Navigator at a rural nonprofit, 116-bed acute care facility in the State of Virginia met with interdisciplinary team (IDT) members to identify improvement efforts to decrease 30-day readmission rates.

Primary practice setting: A 116-bed health care facility in Southside Virginia.

Methodology and sample: Quality improvement initiative aimed to decrease 30-day penalty readmission rates using a collaborative IDT approach, focusing on patients 65 years or older who are discharged home or to an assisted living facility with a diagnosis of acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia.

Results: Compared to the readmission rates obtained in 2022, the 2023 readmission rates among the four diagnoses groups met or were under the disease-specific targets for 2023, supporting the efforts of the collaborative interdisciplinary approach to decrease 30-day readmission rates.

Implications for case management practice: Addressing community barriers and social determinants of health at the index admission. Collaborating with IDT members for a safe transition of care. Using the community paramedic program to provide additional resources to a rural community.