What are the best quality indicators to reduce readmissions in case management?

1 What are readmissions and why do they matter?

Readmissions are hospital admissions that occur within a certain time period after a previous discharge, usually 30 days. Readmissions can indicate poor quality of care, lack of coordination, inadequate discharge planning, or insufficient follow-up. Readmissions can also increase the risk of complications, infections, and adverse events for patients, as well as the burden on the health system and the costs for payers. Therefore, reducing readmissions is a priority for case management, as it reflects the effectiveness and efficiency of their interventions.

4 How to apply quality indicators in practice?

Applying quality indicators in practice requires case managers to use evidence-based tools and strategies, such as discharge checklists, individualized care plans, patient education materials, and follow-up phone calls. Discharge checklists are standardized tools that guide case managers and other providers through essential steps and tasks of discharge planning. Care plans should outline the goals, interventions, and outcomes of case management, as well as the roles and responsibilities of the care team and the patient. Patient education materials should be clear, concise, and tailored to the patient's literacy and language level. Follow-up phone calls are proactive calls made to patients within 48 hours of discharge to assess their status, answer their questions, reinforce their education, and address any issues or needs. To ensure quality care is provided, these strategies should be updated regularly with the patient and other providers.

5 How to evaluate and improve quality indicators?

Evaluating and improving quality indicators requires case managers to collect, analyze, and act on data, such as readmission rates, process measures, and outcome measures. Readmission rates should be compared to internal and external benchmarks and targets, with trends and patterns identified and explained. Process measures should be linked to readmission rates and outcomes, while outcome measures should be aligned with the goals of case management and the patient. Case managers should use data to identify opportunities for improvement, implement changes, monitor progress, and evaluate impact. Additionally, they should seek feedback from patients, caregivers, and other providers in order to inform their practice and improve the quality of care.

6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?