Hackensack University Medical Center Reduces Readmissions Through Interactive Post-Discharge Program

Like most hospitals around the country, Hackensack (N.J.) University Medical Center is focusing on reducing readmissions. As part of this effort, the hospital was among four hospitals to participate in a pilot of a new program designed to follow up with patients after discharge to prevent readmissions. Overall, hospital staff at the pilot sites saved an estimated 600 hours, and the hospital found more than 313 "red flags" — conditions that impact patient outcomes, satisfaction and risk.

Dr. Louis E. Teichholz describes a post-discharge program to reduce readmissions at HackensackUMC.Post-discharge follow-up program

The program, EmmiTransition, was implemented for more than 100 discharged congestive heart failure patients at the pilot sites. For 45 days post-discharge, CHF patients received an interactive call from EmmiTransition reminding them to schedule an appointment with their primary care physician, take their medications appropriately and complete other important post-discharge actions.


The voice response calls also asked patients questions, such as their weight to determine any weight gain. These recorded interactions are sent to HackensackUMC to identify any red flags, in which case a nurse from the hospital would call the patient to discuss his or her condition more in depth. One of the most common red flags identified through the calls was weight gain, according to Louis E. Teichholz, MD, medical director of cardiac services at HackensackUMC. By identifying this symptom, HackensackUMC providers were able to intervene early and prevent a potential readmission.

In addition, the program has an online educational component that patients and families can use to learn more about heart failure.

Engaging patients
The interactive component of this follow-up program is one of its greatest attributes, according to Dr. Teichholz. "The concept is to make patients a partner in their care," he says. "It's getting the patient involved to make them part of decision making."

Engaging patients in their care is important after discharge because it encourages patients to make choices that can prevent their readmission. Sometimes patients are more receptive to care instructions after discharge when they are home rather than during the discharge process. "When you talk to patients at discharge, they just want to go home," Dr. Teichholz says. "The learning at that time is not very effective, so we feel a lot of it has to occur afterwards."

Patient engagement post-discharge can also improve their health for the long term, which, when applied on a large scale, can improve population health. "We need to be able to interact with our patients more efficiently both inside and outside the hospital not just to improve readmission rates, but also to improve outcomes," Dr. Teichholz says.

Quality, cost and satisfaction outcomes

EmmiTransition proved to be effective at HackensackUMC in reducing readmissions, improving overall health outcomes and improving satisfaction, according to Dr. Teichholz.

The program also saved staff resources, resulting in cost savings. One particular convenience was saving staff the need to make multiple calls to patients when there is no answer, Dr. Teichholz says. The hospital was therefore able to deploy staff where they were most needed.

More Articles on Hospital Readmissions:

3 Risk Factors for Hospital Readmissions
Study Finds Social Factors Linked to Hospital Readmissions, Mortality

Turning Heart Failure Into Heart Success: Transitioning CHF Patients to Home

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