STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic medical centre

SETTING: Massachusetts General Hospital embarked on a 4-year project to reduce readmissions in a high volume general medicine unit (November 2009 to September 2013). OBJECTIVE: To reduce 30-day readmissions to 10% through improved care coordination. DESIGN: As a before–after study, a total of 7586 patients admitted to the medicine unit during the intervention period included 2620 inpatients meeting high risk for readmission criteria. Of those, 2620 patients received nursing interventions and 539 patients received pharmacy interventions. INTERVENTION: The introduction of a Discharge Nurse (D/C RN) for patient/family coaching and a Transitional Care Pharmacist (TC PharmD) for predischarge medication reconciliation and postdischarge patient phone calls. Other interventions included modifications to multidisciplinary care rounds and electronic medication reconciliation. MAIN OUTCOME MEASURE: All-cause 30-day readmission rates. RESULTS: Readmission rates decreased by 30% (21% preintervention to 14.5% postintervention) (p<0.05). From July 2010 to December 2011, rates of readmission among high-risk patients who received the D/C RN intervention with or without the TC PharmD medication reconciliation/education intervention decreased to 15.9% (p=0.59). From January to June 2010, rates of readmission among high-risk patients who received the TC PharmD postdischarge calls decreased to 12.9% (p=0.55). From June 2010 to December 2011, readmission rates for patients on the medical unit that did not receive the designated D/C RN or TC PharmD interventions decreased to 15.8% (p=0.61) and 16.2% (0.31), respectively. CONCLUSIONS: A multidisciplinary approach to improving care coordination reduced avoidable readmissions both among those who received interventions and those who did not. This further demonstrated the importance of multidisciplinary collaboration.