ST. JOHNS REGIONAL MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

Months 1-3:
1. Patients identified as high risk for readmission will be prioritized for a nurse follow-up call within 3 days of patient discharge from the hospital.
2. Patients readmitted within 30 days will be reviewed by quality and patient safety coordinators to determine if there were opportunities for improvement in the first admission that might have prevented a readmission. Physician review will follow if there are opportunities attributed to physicians; if there are system opportunities, the conclusions of these reviews will be shared with appropriate leaders and committees for their action planning and implementation.
3. A spreadsheet of contributing factors for readmission will be presented to the Readmission PI Team for focused action planning. These include factors related to the social determinants of health as well as other factors identified by the review process.
4. All of this information including data, conclusions and recommended action strategies will be presented to the Readmission Reduction PI/UM Team monthly for input, feedback and final action plans.
Months 4-9:
1. Tailored Discharge Instructions addressing key metrics on early identification of readmission factors are shared with patients prior to discharge. Employ a patient or caregiver teach-back process for all necessary key instructions particularly symptom management.
2. Include patient key caregivers and engage them in an early state including all essential elements of the patient's experience from assessment to care planning, education and discharge instructions. A key focus of this engagement will be education about symptom management.
3. Timely transmission of key hospital information included in the discharge summary to primary care providers and other post-acute care providers (home health, skilled nursing home etc.)
4. Symptom management pamphlet, refrigerator magnets and other documents will be developed for the most common diagnoses causing readmissions. These will be designed in a step by step process starting with minor symptoms and action steps to major symptoms and action steps.
Months 10-24:
1. Patient post-discharge phone calls will be made within 24 – 72 hours following patient discharge using a structured format designed to address patient understanding of discharge instructions, medication adherence, and symptom management as well as to confirm their follow-up appointment. This phone call will also be designed to capture any barriers to getting to their follow-up appointment.
2. Patients with identified barriers or those experiencing symptom management concerns will receive a second call within 7 days if needed to support any issues, opportunities or barriers to getting the help needed.
3. Conduct an analysis of opportunities for improvement over the previous 9 months to determine if there are patterns of care, treatment or services that needed improvement. Create and implement an action plan based on the conclusions from this analysis.
4. Create a consortium of post-acute care facilities. Invite key leaders from each facility to an initial meeting where common/shared goals are created and each facility has an opportunity to present their strengths and competencies. One of the shared goals will be the prevention of hospital readmissions.
5. On a quarterly basis the consortium would meet to review readmissions, discuss progress to goals, identify patient care needs, education needs or other factors designed to reduce readmissions.

3. Structural Measures

4. Web Address for Equity Report

https://shorturl.at/DyqIf

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

6. Looking for Related Reports?

• Community Benefit Plan
• Hospital Supplier Diversity Plan
• Hospital Fair Billing Policies
• Hospital Profile