(P38) Enhancing Communication Processes to Decrease Readmissions in Post-Acute Care.

Objective/Aim: We aim to understand the causes of and decrease the rates of readmission in the SNF by implementing new communication channels with nursing and administration directly while preserving patient confidentiality, safety, and health.

Background: Nationally, hospitalized Medicare patients have been noted to have readmission rates of nearly 25% when discharged to a SNF. In previous studies, for every 200 patients readmitted, nearly 67% were preventable.

Quality Improvement

Methods: We analyzed the number and causes for readmission at a 220-bed, preferred post-acute care provider (PACP) of our university-based health system (UBHS). We used a monthly review system consisting of staff at UBHS and PACP in addressing readmission rates. We created summary indicators consisting of measures of; quality of care (addressing falls, catheter associated UTIs, and COVID vaccines rates), Efficiency (subacute median of length of stay), care coordination (handoff and follow-up appointments made), and return to hospital (30-day readmissions). We enhanced our communication system via a HIPPA-compliant texting app that included the inpatient geriatric consult team, the PACP team, and facility admissions administrators, to coordinate discharges to and readmissions from PACP. Prior to implementation readmission rates were 24%, with an average of 5 patients per month within 30-day window.

Results: The average number of total 30-day readmissions, excluding observation and planned, was 5 prior and 9.75 after implementation. We examined possible confounding variables including increased number of falls and wounds. The previous average was 35 falls, with 2 with serious injury, after implementation 45 falls, with 1 with serious injury. The number of patients with wounds was 70 patients prior to implementation and 78 patients after. Also, we noted little change in the number of Covid19 positive patients, prior average 3, current average 4. The readmission rates went from 21% to 42.7% in a matter of 4 months. Our handoff rate was 100%, additionally we found provider- administrator satisfaction increase based upon separate survey analyses conducted before and after implementation.

Conclusions: The enhancement of communication enabled us to provide better handoff and outpatient follow-up. We noted an increased readmission rate from 21% to 42.7%. This rise in rate could have been attributed to the increase in patients with wounds and number of falls within the study. We also observe an increase in the number of planned and observation readmissions after implementation. This could be an indicator that the communication between physicians and administration improved. Important contributing factors to readmission such as medical complexity, premature discharge, and goals of care initiatives likely contributed to our increases.