Care Management Revamp Helps Keep Readmission Rates Low.

Thanks to a series of initiatives to focus on at-risk patients after discharge, Flagstaff Medical Center has avoided readmission penalties for four years and consistently has a 12% all-cause Medicare readmission rate. Inpatient care coordinators assess patients in the hospital and refer those who are at risk to the outpatient care management team, which visits the patients in the hospital and determines the appropriate post-discharge interventions. Depending on their risk scores, patients may receive home visits from coaches, telephone calls from care managers, telemedicine monitoring, or a combination of interventions after discharge. Care coordinators who staff the ED 24/7 set up services including home health, skilled nursing transfers, hospice consults, and other interventions, when appropriate, to prevent a readmission. Utilization review nurses are a resource with physicians when they determine patient status.