Emerson Hospital Launches Comprehensive Approach to Reduce Hospital Readmissions


Emerson Hospital has launched a two-year program designed to reduce readmissions of its hospital patients while improving their care.  The Massachusetts Health Policy Commission awarded a $1.2 million investment to Emerson, known as a CHART investment – Community Hospital Acceleration, Revitalization and Transformation. The purpose of the investment is to improve care transitions and reduce readmissions of patients who are identified by hospital clinicians as high-risk.

“We are proud to have been selected by the State to receive a CHART investment,” said Christine Schuster, president and CEO at Emerson Hospital. “Our focus has always been on providing high-quality, compassionate care to all members of the community.  CHART enables us to provide special focus on patients who are high-risk, and give them the information and tools they need to live healthy and prevent future hospital stays.”

Patients can be readmitted to a hospital for many reasons, the more common ones include: medication discrepancies, delays in post hospitalization care and gaps in planning for transitions of care.  Emerson’s readmission rate is historically, and continues to be, below Massachusetts’ state average. However the hospital recognizes that improvements can always be made to enhance patient care and further reduce readmission rates.

“At Emerson we always strive to provide exceptional care to patients,” said Dr. Gregory Martin, Chief Medical Officer and Senior Vice President for Clinical Affairs at Emerson Hospital. “Our aim with the CHART program is to improve care transitions – the communication and care a patient receives when they leave Emerson. With the additional services supported by the CHART investment we are able to improve the discharge process and ensure better care to our high-risk patients after discharge. This will significantly reduce repeat hospitalizations.”

The goal of Emerson’s CHART program is to reduce 30-day readmissions among high-risk patients by 20% by October 2017. A team of clinicians throughout the hospital, comprised of social workers, a palliative/hospice nurse, pharmacist, project manager and director of care management are working together to meet this goal. To do so, the CHART team is focused on the following:
• Improving communication and collaboration with skilled nursing facilities when patients are discharged from Emerson to nursing centers
• Following up with patients after discharge both by phone and in their homes
• Enhancing discharge planning and scheduling clinical follow-up appointments for patients
• Improving medication compliance and safety
• Developing care plans to guide patient care in the emergency department
• Assessing causes of readmissions and determining ways to reduce readmissions
• Increasing access to pertinent clinical data to assess high-risk patient care
• Providing access to a social worker from Emerson’s partner, Minuteman Senior Services
• Improving end-of-life planning with Care Dimensions, Emerson’s hospice and palliative care partner

“Community hospitals play a critical role in the Health Policy Commission’s efforts to achieve the Commonwealth’s cost containment and quality improvement goals,” says David Seltz, Executive Director of the Health Policy Commission. “In making these vital investments, CHART hospitals were issued a challenge: propose initiatives that will put you on a path of transformation, while meeting critical health care needs of your community. Emerson Hospital met that challenge and we look forward to continuing to partner with them and the communities it serves to build a more coordinated and affordable health care system.”

How CHART Helps Patients
Patients are considered high risk and are identified for the CHART program if they are admitted to Emerson with a primary diagnosis of cancer, stroke, diabetes mellitus, COPD (chronic obstructive pulmonary disease), heart failure, AMI (acute myocardial infarction), pneumonia or end stage renal failure, or if they meet prior utilization criteria at the hospital.

CHART enables high-risk patients to receive extra resources to prevent readmission – at their bedside and at home, or when they are discharged to a nursing facility. For example, while they are in the hospital, CHART patients receive a visit from a pharmacist to review what medications they are taking, why they are taking the prescription, what their local pharmacy has in stock, and ensure there are no drug-drug interactions. The patients leave the hospital with a clean medication list that is sent to all treating providers. This improves care and helps reduce readmission rates.

In addition, because depression is prevalent among individuals with a chronic illness, which can be a barrier to complying with medical treatment and hospital discharge orders, a social worker visits some CHART patients after discharge at their home or a facility.  The social worker helps motivate the patient to manage their health and reduces obstacles that prevent them from doing so, such as identifying ways they can pick up their prescriptions easily.  During the visit, patients are taught relaxation exercises to reduce anxiety, which can often exacerbate chronic illnesses. The social worker can also make critical phone calls with patients in their own home to get them the resources they may need.

As the CHART program at Emerson continues, the team is identifying additional ways to further improve the work of transitioning patients from the hospital to their next place of care – be it home, a nursing facility, or other location. Currently, CHART patients are those who are considered high-risk and are on the medical, surgical and psychiatric units at Emerson.

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Emerson Hospital is a multi-site health system headquartered in Concord, Mass., with additional facilities in Sudbury, Groton and Westford. The 179-bed hospital provides advanced medical services to more than 300,000 individuals in 25 towns. To learn more, visit www.emersonhospital.org.