???Reducing unnecessary hospital readmissions is a top priority in health care today. This program is making measureable strides in addressing this issue ??? particularly among our most vulnerable patients ??? through comprehensive team-based collaboration inside and outside the hospital, plus enhanced communication with patients, their families, and caregivers.??? - Antoinette Wilson, PA-C, UPMC Latterman Family Health Center


Grant Application

Antoinette Wilson, PA-C, James Dombroski, MD, James Dombroski, MD, Deepa Burman, MD, Tracey Conti, MD, Barbara Nightingale, MD, Nicole D’Antonio, PharmD, Brenda Krestar, BSW, Shari Holland, MA, LPC, Audrey Moss, RN, BSN, CCM, and Kelly Fozard, UPMC Latterman Family Health Center and UPMC McKeesport Case Management Department


Proposed Innovation

Avoiding unnecessary hospital readmissions is key to providing quality health care for patients. Too often, however, discharged patients are confused about how to care for themselves at home, are unable to follow instructions, or are unable to seek the necessary follow-up care. This puts them at risk of having to return to the hospital for care.

In 2014, the Beckwith Institute funded a project aimed at reducing readmission of patients from UPMC Latterman Family Health Center following hospitalization at UPMC McKeesport. Patients identified as being at a high risk for readmission were referred to an outpatient-based Transitional Care Team, which met with patients to determine care goals and perform a pre-discharge home evaluation. The team also collaborated with the inpatient team to develop a specific plan of care following discharge. This current project builds on the success of the initial project by expanding on the involvement of other members of the healthcare team during and after hospitalization.


Improvements in Action

This project is unique because it introduces the collaboration between healthcare team members (a hospital-based Community Outreach Team and outpatient-based Transitional Care Team) while the patient is hospitalized. Patient engagement begins at the bedside and continues with an at-home visit by familiar faces — team members who include a physician, physician assistant, social worker, pharmacist, and behavioral health specialist. Follow up continues with weekly phone calls for four weeks and monthly phone calls for six months. In addition to assessing the patient’s condition and medication compliance, team members work with the patient to address barriers to success, including depression, pain, and addiction as well as inability to navigate the healthcare system, poverty, and lack of transportation.


Results – In Progress

Success will be measured by a reduced readmission rate resulting from patient self-awareness, ability to monitor symptoms, and open access to the primary care team. During the first phase of the project, the 30-day readmission rate dropped from 18.7 percent to 13.4 percent. The goal for the second phase of the project is to reduce the readmission rate to 13 percent.