Reducing Readmissions Through Follow-Up Appointment-SIPOC Readmission JG

SIPOC Readmission JG

Pdf Summary

This document outlines a hospital inpatient workflow designed to reduce 30‑day Medicare/Medicaid readmissions for patients with CHF, COPD, pneumonia, and AMI. Patients typically enter the process through the Emergency Department or Surgical Services and are admitted to an inpatient unit. Upon admission, the RN completes an initial and readmission risk assessment. If the patient is high risk (or scores >60/100), an Individualized Plan of Care (IPOC) is created to trigger early Case Management involvement and a post‑discharge follow‑up phone call.<br /><br />Within 48 hours, Case Management automatically assesses moderate- and high‑risk patients and documents needs in Cerner, including insurance coverage and required services such as home health or placement. Throughout the stay, the RN provides education on the disease process, medications, and the plan of care. PT/OT evaluates patients—especially those living alone—for ADL support needs and discharge safety, and may continue follow‑up during admission. The RN, case manager, and hospitalist collaborate daily on discharge planning and orders.<br /><br />Near discharge, the hospitalist writes discharge orders (home routine, home with home health, or extended care placement). The discharge nurse is expected to complete discharge within 120 minutes of the written order and document patient discharge education in Cerner. The HUC schedules a primary care follow‑up appointment and documents it in Cerner, notifying nursing leadership if an appointment cannot be arranged (e.g., no PCP, PCP refusal, insurance/COVID barriers).<br /><br />After discharge, Cerner triggers a leadership follow‑up call for high‑risk patients within 5 days. If the patient is readmitted within 30 days, a unit case management readmission trigger initiates review and an updated discharge process. A Quality RN and Case Management analyze reasons for readmission and coordinate with the hospitalist/provider.

Keywords

hospital inpatient workflow

30-day readmission reduction

Medicare Medicaid readmissions

congestive heart failure (CHF)

chronic obstructive pulmonary disease (COPD)

pneumonia

acute myocardial infarction (AMI)

readmission risk assessment

case management within 48 hours

Cerner documentation and follow-up calls