An interdisciplinary approach to reducing hospital readmissions

Care navigation Care transitions Clinical collaboration Reducing readmissions
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Dina Walker
Encompass Health National Director of Case Management at the company’s annual Director of Case Management Conference

Evolving care collaboration—that was the theme of Encompass Health’s recent case management meeting.

Held in San Antonio, Texas in September, the conference brought together the company’s more than 100 directors of case management, as well as other company leaders. The focus was on clinical collaboration and reducing readmissions, and the conclusion: it takes everyone working together to get the patient home and keep them home.

“It really does take village,” said Encompass Health National Director of Case Management Dina Walker. “You can’t over communicate or network enough. It’s all about doing right by the patient.”

From admission to discharge, the patient’s care team should be in constant communication, and the individual at the heart of that communication is the case manager, ensuring patients and their caregivers understand their care plan and are prepared to transition to the next setting of care.

However, with an industry-wide focus on value-based care and reducing readmissions, the case manager’s role is evolving to go beyond discharge to get the patient home and keep them home.

Just as Encompass Health takes an interdisciplinary approach to patient care, it’s doing the same with tackling hospital readmissions. At the DCM meeting, leadership from all areas of care, addressed how they are working to get patients safely home and keep them there, especially during those critical days right after discharge from the rehabilitation hospital.


Mismanagement of chronic illnesses, such as COPD, diabetes or congestive heart failure, often lead to hospital readmissions. That’s why it’s imperative nurses educate patients on those chronic conditions before they leave the inpatient rehabilitation hospital, said Mary Ellen Hatch, Encompass Health’s vice president of nursing operations.

“These chronic illnesses, patient think they’ve got it, and nothing has changed,” she said. “But it’s changed a lot. First, we have to open their eyes on how to manage this and how it might be different after a stroke or motor vehicle accident.”

She encourages nurses to use the “ask three, teach three,” method, asking the patient three questions about their medications, and if they can’t answer them, educating them again, to ensure they understand how medications affect their management of a chronic condition.


With a focus on function, Cheryl Miller said therapy can better prepare patients for those everyday tasks they’ll face when they return home.

“We’re really focusing in those iADLs—instrumental activities of daily living,” said Miller, vice president of therapy operations. “Those are cooking, medication management, banking, laundry, pet care and shopping. We’re thinking more about just getting someone walking; we’re thinking about those things that used to bring them joy and meaning.”


Preventing medication-related readmissions should start at admission to the inpatient rehabilitation hospital, said Shawn Meyers, national director of pharmacy.

“So many pharmacy directors tell me that if you invest time in the admission piece, it makes the stay better and the discharge smoother,” he said. “You’ve cleared up all the discrepancies of data. It always comes back to how well you do at admission.”

When it comes to discharge, Meyers said the focus should be on education, but don’t overload patients.

“If a patient comes in on 13 medications, and 11 they’ve been on forever, but two are pretty new and started at the acute care hospital, you really don’t need to print all of them. That would probably overload a patient with information that doesn’t add value, and the two new meds are buried in there … Make sure they understand the new ones.”

Home health

Clinical collaboration among Encompass Health inpatient rehabilitation hospitals and home health locations are improving the patient experience, reported Kristi Wimberly, director of care transitions.

When the company added its home health segment nearly five years ago, it developed a standardized clinical collaboration protocol in its overlap markets—where there is an Encompass Health rehabilitation hospital within an approximate 30-mile radius from an Encompass Health home health location.

“When we collaborate, our patients win,” Kristi said. “Out outcomes are better.”


Encompass Health is taking clinical collaboration to the next level with its readmission prediction pilot.

Nearly a decade ago, Encompass Health invested more than $200 million to develop a proprietary electronic medical record. Thanks to that investment, the Company is now using data from that EMR to develop predictive models to reduce the risk of a readmission.

It first developed ReACT, which runs in all the Company’s 130+ hospitals, to reduce the risk of a readmission occurring during the inpatient rehabilitation stay, and is now piloting a readmission prediction model that predicts a patient’s risk of a readmission up to 90-days after discharge from the hospital.

Walker said they are continuing to learn from the pilot. For instance, greater focus is being given to the first few days a patient leaves the inpatient rehabilitation hospital.

“This first five days are critical,” she said. “The already high risk patient is very vulnerable those first few days after they leave us. We have to bridge the gap.”

The pilot has also shown that predictive analytics can only determine so much; it’s up to that key individual, the case manager, to factor in social determinants of health that also contribute to hospital readmissions.

And once a high-risk alert is triggered, clinicians need to know what to do to prevent that patient from going back to the hospital.

“The algorithm is just an assessment of risk,” Walker said. “We’re also building intervention strategies.”

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