1. Engaging a Microsystem to Reduce 30-Day Readmissions on an Acute Care Unit
Erin Johnson, MSN, RN,
Sara Stetz, MSN, RN

2. Background
A microsystem is a group of front line staff who work together to provide care and is effective when shared goals are strategically created to improve performance.

3. Background up to 79% of hospital readmissions may be preventable.
Facility performance data includes 30 day readmission rates.
Up to 20% admits are re-hospitalizations within 30 days of discharge.
Harmful, expensive and represent a significant area of waste and inefficiency in the current delivery system.
Decrease access to care, reduce inpatient flow, and waste scarce clinical resources.
Traditional methods of a single discipline creating interventions for specific diagnoses did not impact readmissions at the facility.
Health Policy Brief by Health Affairs:
up to 79% of hospital readmissions may be preventable.

4. Background
The article suggests that readmissions are a result of poor coordination between inpatient and outpatient care, a lack of understanding from the patient perspective at hospital discharge, and a lack of timely follow-up post-discharge.

5. Purpose
The purpose was to strategically engage an interdisciplinary microsystem to evaluate 30 day readmission data, identify patient populations, and develop multi-disciplinary interventions across the continuum of care to decrease 30-day readmission rates.
Started at 14%, goal was to decrease below 12%

6. Methods
Interdisciplinary members from acute and primary care were identified as the clinical microsystem.
The team analyzed two years of readmission data; then focused on identifying population traits.
Review of literature noted a wide range of factors related to readmission beyond diagnosis
Readmission interviews
Risk assessment tool
Post discharge social work appointments

7. Methods: Interviews
Patients were taking medications, had follow up appointment and understood discharge instructions. It was noted that mental health could have been a barrier to following discharge instructions.

8. Methods: Risk Assessment
LACE risk tool: calculates a readmission risk score
Length of stay,
Acute admission through the emergency department (ED),
Comorbidities and
Emergency department visits in the past six months.
Manual process, labor intensive
A review of literature noted a wide range of factors related to readmission beyond diagnosis and the benefits of a risk assessment tool in clinical care based on information found in Up-to-date, Hospital discharge and readmission article. The Previously, the tool was completed after discharge by social work and case management was offered by letter. The action was found to be too delayed.
The group developed a new trial to complete with the LACE tool while patients are hospitalized on the unit, instead of after discharge. The LACE assessment was done on hospital day one. The Continuity of Care Coordinator RN performed LACE tool assessment Monday through Friday and the charge nurse completed on the weekends.

9. Methods: VA Innovation
The Care Assessment Need (CAN) score, from Primary Care data sets, uses predictive analytics to calculate risk and is expressed as a percentile ranging from 0 (lowest risk) to 99 (highest risk).
The CAN score was adapted as a tool to measure risk for readmission on the medical-surgical unit.
High score
Risk 3%
at one year
Released in Predictive tool.
Risk 72% at
one year
Low score

11. Methods Data Review for 6 months of process:
45 unique patients with CAN 98 or 99
SW follow through on high risk patients
Readmitting dx
27% Palliative care involvement
24% Readmission within 30 days of discharge
Consistent follow through by SW unless intensive case management by homeless program, substance abuse program or home based primary care, or d/c to nursing home.
Trying to assess population by readmitting dx, no trend
Palliative were involved in 27% of high risk patients, flagging them for careful discharge planning

12. Methods Readmission interview showed no gaps in services
Risk identified required follow up from Primary Care
Developed process for social work follow up
Consult entered on high risk patients
Originally, patients with high risk scores were given two follow ups depending on score. One group was scheduled for a social work appointment on same day as primary care (PCP) or other specialty follow up. Patients who scored greater received an outpatient social work (SW) consult (for warm hand off) in addition to a scheduled social work appointment with their follow up. After the trial, SW appointments were changed to social work consults due to difficulty with coordinating with PCP follow ups. The follow up can be by phone or appointment.

13. Results
Demo here

14. Results: Patient Experience

15. Results

16. Results 8.

17. Conclusions/Implications for Practice
Interventions based only on admitting diagnosis or unilateral work by a single discipline does not effectively decrease readmission rates.
Identifying and leveraging microsystems creates cohesive care and sustainable solutions.
Risk assessment tools consider multiple factors related to readmission and are an effective method to screen patients.
Strategic use of data created direction for future work including focus on mental health, palliative care, and oncology co-morbidities.