The grant, given in 2015, was part of the Community Hospital Acceleration Revitalization and Transformation Program, or CHART, which includes  27 community hospitals seeking to cut 30-day readmission rates among high- risk patients.

Emerson’s readmission rates were already lower than the state average, but improvements during the grant’s two-year span have cut  rates for the hospital’s high-risk patients by 24 percent. At the same time, patient satisfaction,  as measured by Emerson’s HCAHPS scores, is now trending in the 96th percentile, up from  around 65 percent before it entered the program.

Emerson officials said the improvements  required a change in culture and stronger coordination  within the hospital and across the community it serves.

The grant called for staff to analyze their high-risk patient population and ask exactly who were the high-risk patients that the hospital needed to be most worry about, Margaret Foley, R.N., director of care management at Emerson, told Hospitals & Health Networks.

H&HN reported: “Emerson looked within its hospital walls to better address the needs of high-risk patients by placing a renewed focus on them — educating staff on addressing needs from the perspective of the patients, their families and their caregivers. Asking questions like: How were they functioning at home? What was life like for them? Have their health goals changed? And how do we take in and use that information? Foley says.”

“Additionally, new staff were brought in and interdisciplinary teams were created to care for the entirety of patients’ needs. A nurse navigator had already been in place to make sure that more than just clinical needs were being met, and dedicated social workers, care transition nurses, navigators and pharmacists joined the team to provide more well-rounded care. And a community worker is now able to help patients get to appointments on time, understand what a doctor tells them and follow up after they’re outside the hospital walls.”

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