The Readmissions Reduction Coordinator (RRC) is responsible for improving patient wellness, reducing unnecessary ED visits, admissions and readmissions, and ensuring appropriate utilization of healthcare resources. This is achieved by monitoring the SLHS continuum of care for patients discharged from SLHS Hospitals; which includes discussing utilization patterns of community services, including hospitals, post-acute care providers, home health, and short-term and long-term care facilities. The RRC will collaborate with Hospital Leadership and care teams, such as; Case Managers, Social Workers, ER and Pharmacy Care Coordinators and Navigators, as well as Provider Practices to review trends in resource utilization. The RRC will seek to facilitate assistance to patients who express concerns or additional care needs. The RRC will also seek to understand readmission drivers and opportunities to reduce 30-day readmission penalties. This is a temporary position designed to lead to the creation of protocols and practices which will support ongoing readmission reduction practices.
Major Job Objective and description of responsibilities/milestones/key objectives
· Assess reasons for readmission and identify trends.
o Develop in conjunction with the supervisor and other key stakeholders, methods for identifying patients who may seek readmission and design mechanisms for interventions to reduce readmission.
o Work in conjunction with nursing, pharmacy, inpatient providers, emergency department, case management, outpatient provider practices, and post-acute providers to assist in coordination of care with patients at high risk for readmission.
o Evaluate the Post-Acute Referral process and identify opportunities for improvement in a knowledgeable, skillful and consistent manner.
o Assist in the development of departmental policies and procedures, including assessment techniques to evaluate and track patient outcomes.
o Review readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for process improvement.
o Participates in weekly readmission and other type rounds as needed based upon opportunities.
o Attend and actively participate in quality and program team meetings, webinars, and learning collaboratives.
· Effectively utilize available systems and data analytics to understand and influence readmission factors and referral patterns.
o Utilize available SLHS technologies and industry standard evidence-based tools for consideration of appropriate level of care, readmission risk and needed interventions.
o Utilize the case management process to guide service delivery throughout the healthcare continuum to ensure quality care is delivered in the most efficient and effective manner.
o Refer to Population Management personnel and or registry functionality within EHRs, as well as reports from Clinical Quality Metrics and Payer Feedback Reports in order to identify gaps in care around evidence-based guidelines. Utilizes this information to guide the work of Improvement Teams and suggest adjustments in internal workflow to improve patient health outcomes.
o Assess and monitor patient’s appropriateness for care setting according to InterQual (or other available solutions) criteria and/or industry standard evidence-based criteria. Collaborate with Hospital Case Management and providers on identified patients that do not meet criteria and assist with facilitating appropriate discharge setting as needed.
· Review Readmissions Rates and Readmission Retention rates of Post-Acute Providers and initiate discussions with those providers to seek improvements in performance.
o The RRC partners with acute and post-acute interdisciplinary care team members to support discharge planning, resolve barriers and to connect the patient to community resources and additional services.
o Responsible for identifying the appropriate Post-Acute Care (PAC) setting and evaluating transitional needs post-discharge to improve outcomes.
o Work with case management and provider practices to insure that a timely and usable record is developed that informs patient’s providers of necessary information about the reason for the readmission, inpatient care rendered, and outpatient provider role in post discharge care.
o Work with post-acute providers to develop methods of preventing preventable readmissions.
o Document interactions with patient, family, hospital staff, and providers in accordance with the facility-specific documentation policies.
· Establishes relationships with community resources to mitigate patients’ socioeconomic issues that lead to an increase in readmission and healthcare utilization.
o Develop tools to assist patients to procure needed medications and educate patient on use and continuation of certain medications. Work with high risk patients and their providers to develop consistent updated medication lists.
o Provides post-discharge support to care teams to assist patients in meeting short and long-term goals with regards to their overall well-being. The RRC may collaborate with other care team members such as home health providers to avoid redundant follow up and coordinate care.
o Facilitate and coordinate services to develop patient-centered, individualized, and integrated self-management plans that include outcomes and goals, to include assisting patients who do not have a PCP with establishing care.
o Coach, inspire and support change. Assess patient readiness to change, and their health literacy as well as cultural and/or social aspects that may lead to potential barriers.