Closing the Gap | How One Hospital Cut Readmissions by Hardwiring Care Transitions

In late 2016, leaders at Advocate Sherman Hospital, a level 2 trauma center in Elgin, IL, took a hard look at patient HCAHPS rankings and decided they had more work to do. Patients ranked the hospital overall (medical floor) at the 53rd percentile, and at just the 28th percentile for care transitions.

Also, since nurses had been making centralized post-visit calls since 2011, they had identified a host of issues negatively impacting patient transitions after discharge. For instance, patients commonly complained they couldn't get in to see their physician for a timely follow-up visit, had trouble filling prescriptions, and expressed confusion about discharge instructions.

"We knew from our work with Studer Group that the HCAHPS care transitions domain really drives the overall rating," explains Joan Kanute, MS, RD, CNSC, CPXP, executive director, service excellence. "So in retrospect, it's perhaps not surprising that our overall HCAHPS rating jumped to the 89th percentile during the pilot when we got care transitions right." In addition, Advocate Sherman Hospital avoided 41 patient readmissions during its three-month pilot for a net savings of $265,516 (based on an estimated cost of $6,476 per patient) during the quarter.

A Four-Pronged Approach:


When Cheri Goll, MSN, RN, NE-BC, chief nurse executive/vice president nursing and Kanute reviewed readmissions by unit and checked those against post-visit phone calls, they learned that readmissions were frequently caused by gaps in post-visit care, such as delays in the arrival of oxygen at home or inability to get to a scheduled physical therapy appointment. By designing a new discharge process where RNs rounded daily on patients with care managers, they closed the gaps.

To reduce variation in the rounds, they developed a standardized script that was prescriptive and focused on what would be needed at home. For instance, a care manager might say, "Tell me about your home." When the patient described area rugs in the kitchen and an upstairs bathroom, the team could create a proactive and customized plan before discharge that would help the patient avoid falls once they were home.


When members of Sherman's Patient and Family Advisory Council reported that discharge information was confusing, they responded by creating a discharge education task team to streamline a discharge education folder and checklist. They also initiated standard work that included the "teach back" method for several discharge priorities. Instead of asking patients, "Do you have any questions about caring for your wound?," they'd say, "I want to make sure I did a good job explaining. Can you tell me in your own words, how you will take care of this wound?"


To focus callers, the team renamed the calls "transition of care calls". Instead of striving to complete calls to 100 percent of discharged patients, the team used a tool in the electronic health record (EHR) to calculate risk of readmission. COPD and heart failure patients quickly stood out as a top priority for receiving follow up calls.

To ensure callers reached patients easily, they met with patients before discharge to identify the best person and time to call. Callers also took ownership for coordinating patient follow-up at outpatient and primary care clinics. To avoid the issue of patients not scheduling their follow-up appointments, callers explained, "It's important you see your physician within the next few days after your hospital visit to stay healthy. I'll be making that appointment for you."


Because the team had been using Studer Group's automated Patient Call ManagerSM software for sometime, it was easy to take it to the next level. Studer Group coaches Diana Topjian and Lynne Mahony shadowed nurses to help further refine questions for calls and identify more efficient workflows. Color coding high-risk populations made it efficient to identify priorities for both initial and serial calls.

What's Next

Currently, Sherman Hospital is training paramedics that do home visits, transition care nurses, care managers, outpatient chronic care clinicians and primary care physician office staff on patient activation. "More 'activated' patients are more engaged patients, and they have lower health costs as a result," explains Kanute.

"We will be administering a Patient Activation Measures (PAM) assessment to chronic care patients as well as high-risk inpatients and then plan to integrate the result into the EHR. This allows us to spend time and resources on patients who may be more overwhelmed (i.e., less activated) and improve their engagement for better outcomes and lower readmissions."

"Once you implement this approach, it's critical to be out on the floors seeing how it's actually being accomplished day-to-day," suggests Goll. "Hardwiring it might mean addressing people problems, design issues, or challenges with the mental model. It's the only way to identify barriers you didn't anticipate."

  • Cheri Goll, MSN, RN,NE-BC, chief nurse executive/vice president nursing at Advocate Sherman Hospital, Elgin, IL

    Cheri Goll, MSN, RN, NE-BC

    Chief nurse executive/vice president nursing at Advocate Sherman Hospital, Elgin, IL

  • Joan Kanute, MS, RD, CNSC, CPXP, executive director, service excellence at Advocate Sherman Hospital, Elgin, IL

    Joan Kanute, MS, RD, CNSC, CPXP

    Executive director, service excellence at Advocate Sherman Hospital, Elgin, IL

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