Reducing Readmissions Through Follow-Up Appointment-Cause and Effect Readmissions Project

Cause and Effect Readmissions Project - JG

Pdf Summary

This document is a Cause & Effect (C&E) Matrix for a hospital readmissions improvement project. The customer is Hospital Administration, and the two key outputs (Y’s) are <strong>decreasing readmissions</strong> and <strong>decreasing reimbursement losses</strong>, both rated <strong>10/10</strong> in importance. Using a “Fist to Five” consensus approach, the team scores how strongly different process inputs (X’s) correlate to these outputs on a scale of <strong>0 (none), 1 (low), 3 (moderate), 9 (high)</strong>, then totals weighted importance.

The highest-impact inputs (generally scoring high correlation to both outputs and receiving the largest totals) occur around <strong>admission risk identification, discharge planning, and post-discharge follow-up</strong>. Key high-priority steps include: admitting patients from the ED; completing an initial assessment and readmission risk assessment; creating an individualized plan of care (IPOC) for high-risk patients; case management (CM) assessment of needed services within 48 hours for moderate/high-risk patients; ensuring safe discharge orders with the correct level of care; and PT/OT evaluation when patients live alone or need help with activities of daily living.

Discharge and follow-up activities are also emphasized. High-scoring inputs include: HUC scheduling and communicating primary care provider (PCP) follow-up appointments (including addressing cases where patients have no PCP or a PCP refuses follow-up); RN discharge education; confirming follow-up appointments; evaluating whether the patient should go home, receive home health, or be placed in extended care; and using Cerner triggers for follow-up phone calls for high-risk readmissions.

Post-discharge monitoring includes a 30-day readmission trigger to case management to reassess level of care, identify readmission reasons, and notify providers. Lower-scoring items include some consult/insurance documentation tasks and the provider writing a discharge order, which show weaker correlation in this matrix.

Keywords

Cause & Effect Matrix

hospital readmissions reduction

reimbursement loss prevention

readmission risk assessment

discharge planning

post-discharge follow-up

case management assessment

primary care follow-up appointment scheduling

RN discharge education

Cerner readmission triggers