This article appears in the March 2013 issue of HealthLeaders magazine.

Editor’s note: This article is excerpted from a longer case study that is available as part of the upcoming April 18 event, HealthLeaders Media Live from Parkview Health: The New Readmissions Plan. For more information on the event, visit www.

Too often, hospital-based care teams start to develop a plan for readmissions as part of the traditional discharge process. Maybe a patient navigator is brought in or the education nurses are consulted, often in the last hours of what has likely been a prolonged inpatient stay. It’s just not the best time to start planning for an effective transition of care, says Greg Johnson, DO, chief medical officer of Parkview Health based in Fort Wayne, Ind.

“Typically in the last two hours of the admission the nurse is trying to get everything done and the patient’s thinking about getting home, and it’s not an ideal state for learning, retention, and understanding,” Johnson says. “So one of the things we’re doing is we’ve moved our discharge education to begin at the day of admission.”

The first step is to identify patients on admission who might be at risk for readmission, most often for congestive heart failure, diabetes, pneumonia, acute myocardial infarction, and chronic obstructive pulmonary disorder. Patients who may be at higher risk for readmission include those who have already been readmitted within the past 30 days, those who have an overall elevated number of admissions in the past 6–12 months, or those whose combination of demographic and clinical data put them at high risk, Johnson says. Then Parkview’s transition care nurses get an email alert so they can make contact with that patient on the day of admission, or within 24 hours at the latest, he says.

“The key is that early, consistent contact helps build what has often been missing in preventing readmissions: relationships with the patient,” says Johnson. “Bringing the transition care nurse in at the initial hospitalization begins establishing a relationship. They touch bases with them. They will actually set up the expectation that there’ll be some telephone monitoring within 48 hours of discharge and at least weekly until the end of the 30 days. They’ll help recognize and manage symptoms. They’ll make sure appointments and medications are being adhered to. They’ll help with education to see if the patients and their caregivers are following their diet or whatever the plan of care may be.”

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