Healthcare News & Insights

Case study: Reducing readmission rates via interactive patient screenings

Every hospital is looking for ways to reduce its readmission rates. But it’s not an easy feat, and many variables affect it. In this guest post, Holly Gould, clinical outcomes coordinator for a hospital in Michigan, shares how her facility is accomplishing this task one step at a time.


Like all hospitals, McLaren Port Huron in Michigan is constantly searching for ways to reduce our readmission rates. No small task, considering that one of every six discharged patients in the United States is readmitted in fewer than 30 days, and a third of those within only seven days of discharge, according to a March 2019 article from Forbes.

As McLaren’s clinical outcomes coordinator, I’ve done a lot of research over the years to discover the best way to do this. And everything I’ve read points to one thing – readmissions can be largely attributed to what happens after the patient leaves our care. Even with a team of the most dedicated physicians, nurses, and other clinicians, we can only do so much to address factors such as healthy eating, medication adherence and the availability of transportation to follow-up appointments after the patient is discharged. And it’s precisely these factors – all impacted by larger social determinants of health (SDOH) to one degree or another – that influence whether (and how soon) our inpatients become readmission statistics.

In fact, a report from the Yale Global Health Leadership Institute notes that actual medical care only makes up 20% of what determines a patient’s health; the rest is determined by genetics (20%) and the majority by social, environmental and behavioral factors (60%).

Making a connection

Armed with the knowledge that SDOH were impacting our readmissions numbers, I decided to work with a patient engagement technology company that not only helps us identify SDOH factors but also coordinates with local community resources in our area to help our patients get the services they need. This is a win-win strategy – better health outcomes for patients, reduced readmissions for us, and lower costs across the board.

We first implemented the patient screening technology with our chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) inpatient population in March 2018, largely because these two conditions account for a significant proportion of our readmissions. According to a study published in the Journal of the COPD Foundation, 10% to 20% of COPD patients are readmitted within 30 days, and those who are readmitted have worse outcomes and a greater risk of mortality than those who are not.

The numbers for CHF patients are no less daunting. According to a study in the International Journal of General Medicine, “Chronic heart failure (CHF) is the most common cause of readmission for Medicare patients in the US.” The study found that the 30-day readmission rates among CHF patients were 9.42% and 9.17%, for derivation and validation cohorts, respectively.

The technology solution we implemented to help combat these statistics starts with screenings that our case managers offer to patients via a tablet within 24 hours of admission. The screening consists of questions about food scarcity, transportation, social/family support networks, exercise habits and more. The COPD and CHF screenings include disease-specific education, questions and information in addition to the standard SDOH content. Patients who agree to take the screening receive regular text messages with medication reminders, wellness tips and more for up to 30 days after discharge.

Based on patients’ individual screening responses, the technology identifies patients who are at high-risk for potential readmission as a result of their personal SDOH factors and sends an alert to our case managers. As a second step, the technology company proactively reaches out to the appropriate local resources in our community to help ensure the identified SDOH needs are addressed. The company communicates directly with the patient and the community resources to coordinate service delivery. If a connection can’t be made, they alert us again to let us know that the patient may now be at even greater risk for readmission.

Based on initial positive results, we’ve recently expanded the use of the screenings from our COPD and CHF patients to our entire inpatient population — our case managers have offered the screening to more than 600 patients in the past year.

Gradual change

We already know that identifying those at highest risk for readmission and connecting them to the services they need is crucial in reducing readmission rates. The previously mentioned Journal of the COPD Foundation study notes, “A number of interventions have been proposed to reduce readmissions. However, these interventions have not shown a reduction in readmissions and mortality. One reason may be the inability to identify patients at the greatest risk of readmission and to target resources to these high-risk patients.”

As a result of McLaren doing more to identify and address the SDOH needs of our patients, and of educating them and involving them in their health care plan, we’ve significantly reduced our readmission rates in recent months. In FY 2018, McLaren’s Medicare penalty percentage for 30-day readmissions was 2.34%, while in FY 2019 that number is hovering at 1.85% (as of April). In fact, our overall all-payor readmission rate is trending down as well; we’re definitely heading in the right direction.

Holly Gould is the clinical outcomes coordinator at McLaren Port Huron hospital in Michigan. She can be reached at



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