Case Management

Sneak peek: Checklist tool helps staff evaluate entire patient, identify readmissions

Case Management Weekly, May 26, 2010

Before creating and implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson Hospital in Council Bluffs, IA, already had a readmission rate of 8%. Despite its already low rate, increased regulatory focus on readmissions prompted Lorrie J. Reddish, RN, the hospital’s lead case manager, to reevaluate the case management department’s understanding of readmissions. 

Reddish began by speaking with her staff. “When I started talking to our case managers, everybody had a different idea of what was important to refer a patient to home health or a lower level of care,” she says. 

The differing opinions had much to do with the area of the hospital in which case managers worked. New case managers also had different ideas regarding which factors could be a warning sign of possible readmission. 

Reddish created the referral tool using information from those conversations and from “Identifying Potentially Preventable Readmissions” published in the Fall 2008 issue of Health Care Financing Review

As the tool’s name suggests, patients identified as readmission risks receive a referral to a social worker, who then arranges for necessary postacute services (e.g., home health, skilled nursing, insurance applications). 

The tool helps case managers at Jennie Edmundson identify patients’ readmission risk upon admission and throughout their stay. 

Check out the June  2010 issue of Case Management Monthly to learn more. You also can discover the benefits of becoming a Case Management Monthly subscriber.

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