Targeting Patient Transitions to Reduce Readmissions

​This story first appeared in IHI's 2013 Progress Report.


Reducing hospital readmissions by 20 percent within two years is no small goal. But the Ohio Hospital Association (OHA) has made significant progress in achieving this aim. One critical step in its journey was the OHA’s decision to participate in IHI’s STate Action on Avoidable Rehospitalizations (STAAR) initiative. STAAR focuses on improving patient transitions — the pivotal process of discharging a patient from the hospital to their home or to another care setting. During transitions the continuity of care often gets lost, increasing the likelihood of patient readmission.


Medicare data from July 2008 through June 2011: 24.7 percent of heart failure patients nationally were readmitted within 30 days of discharge.

The OHA, which represents 167 hospitals and 16 health care systems throughout the Buckeye state, kicked off its STAAR work at a two-day conference in October 2010 with 18 hospitals participating. At this event, IHI faculty identified four key changes for the OHA member hospitals to implement: 1) identify patients’ post-discharge needs; 2) provide effective teaching and enhanced learning for patients and families; 3) improve communication to patients, families, and post-acute care providers; and 4) provide follow-up once a patient returns home or is discharged to another care setting.


The OHA saw a reduction in both predicted readmissions and absolute readmissions at STAAR hospitals. In one example, for heart failure 30-day readmissions, STAAR hospitals had an 18.37 percent reduction versus non-STAAR hospitals, which had a 5.61 percent reduction.


As a STAAR participant, Kathleen Vidal, RN, MSN, Director of Nursing Practice Development at University Hospitals in Cleveland, Ohio, found one important lesson: identify the key learner in a patient’s family. “You have, say, an elderly man in the hospital and his wife is with him all the time. In the past, you’d just automatically tell his wife everything. But in reality, it’s his daughter who sets up the pills and takes him to the doctor.”



Defining Moment
The transition that takes a patient from the hospital to their home or another care setting marks a pivotal care moment. Zeroing in on what happens during this critical juncture, with the support of IHI’s STAAR initiative, has helped the Ohio Hospital Association make significant progress in its aim to reduce hospital readmissions by 20 percent within two years.


Photo: Tocombamaria K. Murphy, a patient at University Hospitals' Case Medical Center (an OHA hospital participating in STAAR) who had a successful transition home without being readmitted

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