The Heart Hospital at Deaconess Gateway and the University of Southern Indiana Reduce Hospital Readmissions with Successful Program

The Heart Hospital at Deaconess Gateway and the University of Southern Indiana partnered with the Indiana Medicare Quality Improvement Organization (QIO) in 2008, to conduct a three-year national initiative, Care Transitions, designed to reduce re-hospitalizations for their Medicare patients. The final result was a 14.74% reduction in 30-day re-hospitalizations in the targeted community.

Re-hospitalization represents a major opportunity to improve care for patients and families. That is why The Heart Hospital at Deaconess Gateway and the University of Southern Indiana College of Nursing and Health Professions partnered with Health Care Excel (HCE), the Indiana Medicare QIO, to address this important health care topic.

The first step in the Care Transitions project was to receive funding from the Centers for Medicare and Medicaid Services (CMS) to coordinate care in 14 tri-state communities. Once the funding was secure, HCE chose the Evansville Hospital Service area, which included Vincennes, based on opportunity for improvement and strong history of community support. In 2010, having restructured their community, Evansville participated in innovative work focusing on community-based transitions and has further reduced re-hospitalization rates by 13.65% to date. The preliminary results of the project are reported as part of a larger evaluation in the January 23, 2013, issue of JAMA.

Executive Director and Chief Nursing Officer of The Heart Hospital at Deaconess Gateway, Becky Malotte commented, “Through our partnership on Care Transitions with the University of Southern Indiana, we have engaged student nurses and social work students in utilizing the Coleman Model and “Teach Back” model to help set personalized goals with patients and their families. Completing a Personal Health Record provided patients key information to take with them in the transition out of the acute care hospital setting to outpatient and other segments of the health care system. We have continued these efforts with follow up phone calls to our patients and have seen significant improvements in hospital readmissions.” Dr. M. Jane Swartz, Assistant Professor of Nursing at the University of Southern Indiana, stated, “We have seen great student benefits through our participation in this project and have incorporated the Coleman Model into our curriculum here at USI.”

Executive Director Malotte added, “HCE offered The Heart Hospital an opportunity to look at how we could reduce readmissions, be budget conscious, and provide the best quality of care possible for our Medicare patients. The project offered us the opportunity to collaborate with other local health care providers, stakeholders, and partners to bring awareness to this important initiative.”

Currently, The Heart Hospital at Deaconess Gateway is continuing its mission to empower the Evansville community by disseminating educational tools such as medication safety information, personal health records, and important questions to ask when patients are discharged from the hospital.

For more information, contact The Heart Hospital at Deaconess Gateway, at 812-842-4784.

i. The 13.65% is for the current project rehospitalization rates with the 2011 reconfiguration of the community. The rate for 2008 quarterly data from baseline (01/01/2008-03/31/2008) to end of contract (04/01/2010-06/30/2010) is 14.74% relative improvement rate.

ii. Jane Brock, MD, MSPH (2013). Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries. JAMA , 381-391.