Background: The Centers for Medicare & Medicaid Services (CMS) uses a five‐star quality rating system to measure Medicare beneficiaries’ experience with their health care system. Unplanned readmission rates serve as a marker of the effectiveness and safety of its transitional care process and carry significant weight in determining a hospital’s overall rating. Our institution, an 756-bed quaternary care academic medical center located outside of New York City, continues to strive for improved readmission indices and overall improved quality of care. Robust interdisciplinary communication and comprehensive transitional care plans are the backbone of our strategy.

Purpose: As our hospital sought to improve upon its CMS readmission rates, enhancing interdisciplinary care and creating a forum to learn collaboratively about unplanned 30-day readmissions became a priority. An innovative collaboration between our hospital and hospital medicine teams was developed to review cases together in an expedited fashion after readmission, with the goal to better understand discipline-specific processes and identify actionable opportunities for improved transitions of care.

Description: Patients with high-risk diagnoses that re-present to our hospital within 30 days of index discharge are identified by our care coordination team in real-time through an email alert system. If readmitted, these cases are independently reviewed by a group of hospital medicine-based physicians as well as care coordination leaders. If a case is identified by either team for an opportunity for improvement during the index hospitalization, care transition, or in the post-acute setting, these cases are flagged for further group discussion. A weekly, remote, interdisciplinary meeting is held, including the primary attending of record, as well as leaders within hospital medicine, the emergency department, care coordination, local quality improvement teams, nursing, hospice/palliative care, and our outpatient transitional care team. A summary of the case is projected for all to review, and each discipline provides insight into their team’s involvement through the continuum of care. Key components thought vital to a successful transition of care, including adherence to institutional treatment guidelines, timely access to a primary care provider upon discharge, appropriateness of discharge disposition/location, and clarification of advance directives prior to discharge are discussed in more detail. Feedback is given to the primary team in real-time during the calls, as appropriate. The primary team is also encouraged to provide insight into challenges faced during the hospitalization and at the time of discharge.

Conclusions: Since the onset of our initiative in the beginning of 2020, our hospital has noted successive improvements in year-over-year CMS 30-day readmission rates (16.8% > 15.8% 2021 YTD), as well as in disease specific cohorts: pneumonia (18.0% > 15.7%) and congestive heart failure (18.9% > 17.5%). While our success is likely multifactorial, our timely readmission review process, spearheaded by hospital medicine leadership, has been a vital tool in identifying opportunities for clinical quality improvement, enhancing interdisciplinary communication, promoting accountability, and identifying the successes and challenges inherent to transitional care management in an increasingly complex environment. We feel that this model of communication can be easily replicated at other institutions.