Background: Care Coordination Rounds (CCR) provide an opportunity for members of the multidisciplinary health care team to communicate as a group regarding the care and discharge planning of hospitalized patients. The use of CCR has been found to improve efficiency and patient experience, while reducing healthcare expenditures, inpatient length of stay, and unnecessary readmissions. The use of a structured format for CCR has also been shown to decrease adverse events.

Methods: A core multidisciplinary team implemented a standardized process identifying and intervening on patients at high risk for 30-day readmissions. During daily CCR, patients are screened and identified as high risk for readmissions using the Hospital Admit Readmission Risk Discriminator score (HARRD score). The HARRD score incorporates documented electronic health record data on patient age, chronic conditions, number of medications, and history of recent ED visits or inpatient rehospitalizations in the past 90 days. A score ≥ 4 identified a very high risk population encompassing 25% of inpatients with a 30-day readmission rate of 36% (974/2694). Patients at risk are automatically flagged at the time of admission and reviewed by the unit case manager. During CCR, appropriate interventions for the high risk patients are discussed by the multidisciplinary team and incorporated into the discharge planning process. Resources needed are identified and those eligible for close follow up and intensive management in relevant outpatient specialty clinics are so directed. Those patients who refuse or are not candidates for intensive outpatient management are scheduled with a bedside huddle. During a bedside huddle the medical provider, nurse, case manager, social worker, and pharmacist meet at the patient’s bedside for a structured discussion around discharge planning and transitions of care needs. The process was initially piloted on two acute care units, and subsequently was implemented on all 16 acute care units at our institution.

Results: This intervention was associated in time with a reduction of the hospital wide readmission rate by 1.2% in the four months after implementation compared to the four months prior to implementation (13.8% (1261/9126) to 12.6% (1137/8996), p=.019). On average 17 high risk patients per month received bedside huddles. The readmission rate for the patients who received a bedside huddle was 20% versus the historic rate of 36%.

Conclusions: The use of a structured process at CCR to screen and identify patients at high risk for readmission and organize interventions related to transitions of care lead to a meaningful reduction in our overall 30-day all-cause readmission rate.