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Johns Hopkins Pediatric

Driving Down Readmissions for High-Risk Patients with Intensive Care Coordination

October 1, 2016


Johns Hopkins Bayview Medical Center already had a long history of health care outreach to the community, so the state waiver to Medicare’s reimbursement rules rewarding preventive care, enacted in 2014, offered just cause for kicking things up a notch.

A three-year innovation grant from the Centers for Medicare and Medicaid Services to Johns Hopkins Medicine in 2012 set the ball rolling. The approach that Johns Hopkins Bayview and The Johns Hopkins Hospital took “was to focus on improving care coordination to patients who were leaving the hospital,” says Carol Sylvester, Johns Hopkins Bayview’s vice president of care management services.

The hospitals agreed on some specific strategies that the medical center was able to implement all within a year. These included interdisciplinary care planning rounds and early screening of patients to identify those at high risk for hospital readmission — about 15 percent of Johns Hopkins Bayview’s 20,000 annual admissions.

Now, nurse case managers called transition guides tend to patients for the first 30 days after discharge to ensure they have and can take all necessary medicines, and that they’ll keep their follow-up appointments. Transition pharmacy extenders — pharmacy technicians with additional training — make sure patients have all medications and instructions before they leave the hospital.

“We’re about to add that role to our Emergency Department to not only help people with their medications but make sure we get accurate lists of medicine taken at home as patients come in,” Sylvester says. “It’s one of the hardest things to do in the medication reconciliation process.”

Johns Hopkins Bayview’s patient load largely consists of community residents with chronic conditions, says Charles Reuland, its executive vice president and chief operating officer, “We’re pivoting toward public health and trying to both build and be part of a continuum of care that makes more sense than having everyone deteriorate and end up in the ED.”

For example, the majority of the medical center’s discharges that went to skilled nursing facilities now head toward a specific collaborative of five skilled nursing facilities that follow protocols for managing high-risk patients with chronic illness established by geriatrician Michele Bellantoni. As a result, 30-day readmission rates for this population have plummeted from 25 to 30 percent down to 17 percent.

That’s not all. Nurses serving as case managers for patients discharged on intravenous antibiotics visit them in nursing facilities or at home to monitor labwork and adjust doses. Pastoral care students and residents visit frail elders in the house-call program and at the Johns Hopkins Community Physicians office in Dundalk, Maryland. A caregiver initiative funded by the Weinberg Foundation offering support, resources and education for family caregivers of older adults with chronic illness so far has attracted about 300 participants. The medical center also has embedded a mental health social worker within the general internal medicine practice, recognizing that patients may have mental health issues that can affect treatment compliance.

“Our goal is to make our neighbors and neighborhoods healthier and become the trusted hospital of choice in our community,” says Johns Hopkins Bayview President Richard Bennett.

“We’re very pleased that our early results are yielding success. We recognize this as a multiyear investment to identify programs that are going to be the most impactful and are totally committed to this new way of our hospital being funded.”

Adds Reuland, “It’s impossible to count prevented events, but that’s what we’re after.”

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