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Reducing Avoidable Readmissions by Extending Care Beyond the Hospital

Chester County Hospital wants its community to be healthy. In fact, Chester County Hospital wants its neighbors to be in such good health that they don’t need to be hospitalized. That’s why our extensive wellness programs are designed to teach people how to stay well. It’s the reason our caregivers work toward helping their patients achieve a full and speedy recovery. And, it’s why our patients leave the hospital with a personalized discharge plan to help them avoid being re-admitted.

But, even patients who follow the best practices aimed at reducing the risk of hospitalizations – such as attending all scheduled appointments, understanding and following prescribed medication plans, etc. – may find staying healthy a challenge.

Underlying chronic conditions or unexpected accidents can undermine a patient’s quest to be in good health, prompt a visit to an emergency room, or create the need for an inpatient stay. Sometimes, hospitalization just can’t be avoided.

For that reason, Chester County Hospital’s Continuum of Care Program helps patients lessen the likelihood of being readmitted to the hospital down the road.

The Continuum of Care Program launched late in 2015. It was formulated as the hospital and the nation turned its attention toward reducing avoidable readmissions within 30 days of discharge. Reducing readmissions was, and still is, a data point upon which the Centers for Medicare & Medicaid Services (CMS) evaluates hospitals. It started measuring all hospitals against these figures in 2012 when the federal government designed the Hospital Readmissions Reduction Program (HRRP) and began incentivizing hospitals to reduce the number of patients returning within 30 days.

The American Nurses Association (ANA) published a study that showed that 1 in 5 Medicare enrollees is readmitted to the hospital within 30 days, and up to 75 percent of these readmissions are preventable. Since HRRP came into effect, the overall 30-day readmission rate for Medicare patients decreased from 20 percent to 17.8 percent.

Chester County Hospital developed its Continuum of Care Program to improve coordination between the hospital, the patient and their families, the patient’s primary care providers and specialists, and post-hospital nursing facilities.

As the program took shape, a dedicated transitional care nurse met with adult patients* during their hospitalization to reduce the chances that those patients would return shortly after discharge. All the patients on the nurse’s list were identified as high-risk for readmission.

“For the past two years now, the patients we’ve worked with have been happy with this service,” says Mike McGarrigle, director of Case Management of the early findings. “With all the information and new knowledge they learned, they liked having a connection to someone with a clinical background who would also listen to them after they went home.”

As the program now moves into its third year, it is broadening its reach. The goal is to meet with all readmission-prone patients. To achieve that goal, the hospital’s Case Management Department is hiring three social workers to expand the program. They will work to keep patients on a healthy road to recovery and lessen their likelihood of a return trip to the hospital.

“These social workers will become familiar faces and sources of support for patients before and after they are discharged,” McGarrigle explains, adding that they will meet with patients and their loved ones during the first 48 to 72 hours of the patient’s stay to begin educating them about next steps and will stay in contact with them after they are discharged via check-in phone calls 72 hours after discharge, and on a roughly weekly basis for the next month.

According to a study funded by the Agency for Healthcare Research and Quality (AHRQ), “Patients being discharged from the hospital who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow-up appointments, are 30 percent less likely to be readmitted or visit the emergency department than patients who lack this information.”

During phone conversations with recently discharged patients, the Continuum of Care team listens for signs (shortness of breath, lethargy, vocal cues) that may impede their at-home recovery. In these instances, the social worker can encourage the patient to contact their doctor or offer to do this for them. They can make follow-up appointments or contact their physician or family members to discuss observations.

“These status calls give the patients the opportunity to ask new questions and to request services they may have initially declined, such as a home-care nurse,” says McGarrigle. “It opens the door for new conversations about the patient’s health. It creates another opportunity for the hospital to listen to patients and hear their concerns.” The social workers will be liaisons between their patients and their providers, allowing the doctors to enhance, reevaluate or change the treatment plan, if needed.


*The early years of the Continuum of Care Program was limited to Independence Blue Cross patients who were identified as being at high-risk for readmission. The service is not aligned with or funded by any insurance company. Maternity and pediatric patients were not included in the program.


Chester County Hospital’s Diana Walker, Public Relations/Communications Specialist contributed to this article.

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