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Coffee Regional Medical Center

March 8, 2022
for Hospital/Pharmacy/Home Health Staff

Coffee Regional Medical Center, a 98-bed hospital located in Douglas, GA provides high-quality, patient-centered care and has been named a Top Small Hospital in Georgia. As an acute care facility in a rural community with limited resources and an inefficient discharge process as well as inadequate coordination with clinicians and providers, Coffee Regional Medical Center developed the following processes and initiatives as part of their Readmissions Reduction Plan.

  • New Care Management Model: Discharge Planner and Social Worker
  • Addition of a Social Worker in the Emergency Department
  • Revised Discharge Planning Assessment to include a risk for readmission risk score tool
  • Discharge Planning interview conducted on all readmissions
  • Multidisciplinary team daily huddle
  • New Nurse Navigator/TC2 Care Coordinator
  • Discharge post-acute calls within 24 – 48 hours of discharge and weekly calls for 30 days
  • Weekly transition of care calls with HHNS and SNFS
  • Quarterly post-acute care transitions meetings including post-acute providers, Director of Care Management, Social Workers, Senior Leadership, and Clinical Service Directors. Emphasis on process improvement, new services, education, local/state/national and compliance updates
  • Para-medicine EMS pilot study with proven success
  • Meds-to-Bed program
  • Internal readmissions team lead by CMO
  • Review real-time readmission data

Based on the new initiatives and the new Population Health Program/Nurse Navigator, the team was able to reduce readmissions for one patient that had frequent hospital readmissions. See diagram below.

Coffee Regional has been successful in decreasing preventable readmissions and has met the 1% reduction target goal. Current data show an average rate of 22.8%, a decrease of 2.4% over 2019 baseline (25.2%). Congratulations and good work!

For more information, view the entire Community of Practice presentation at:  https://quality.allianthealth.org/conference/hqic-community-of-practice-cop-call-reducing-readmissions-successful-rural-hospital-strategies/