Grant Application

Joy Boone, MD, UPMC McKeesport, in partnership with Daphne Bicket, MD, Deepa Burman, MD, Antoinette Wilson, PA-C, James Dombroski, MD, Tracey Conti, MD, Tamar Carmel, MD, Nicole D’Antonio, PharmD, Brenda Krestar, BSW, Shari Holland, MA, LPC, Audrey Moss, RN, BSN, CCM, and Kelly FozardUPMC 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 for having to return to the hospital for care.

Through this project, patients admitted to the UPMC McKeesport Family Medicine Inpatient Services were assessed for readmission risk. Those identified as being at high risk for readmission were referred to a Community Outreach Team to assist with transitional care. The team met with the patient to determine care goals and preform a pre-discharge home evaluation with the patient’s caregiver. The team also collaborated with the inpatient team to develop a specific plan of care following discharge.


The Community Outreach Team contacted at-risk patients within 48 hours of discharge and met face-to-face with patients within one week. Weekly follow-up phone calls were made during the first four weeks, then monthly for the next five months. Other improvements included daily rounding of the social worker with the inpatient team and a weekly team meeting between the social worker and the outpatient team.


The pre-discharge home evaluation proved not only to be as effective as expected. But shared decision making by the inpatient team and the Community Outreach Team — along with input from the patient and caregiver — helped to identify and correct potential problems, improve transitional care, and reduce readmission of patients. As a result of this project, the 30-day readmission rate dropped from 18.7% to 13.4% for a relative readmission rate reduction of 28.3%. This project has been funded for a second year (see Shared Decision Making 2015-2016).