For many years, Bellin Hospital has been working on reducing readmissions. They utilized the Vizient Playbook tools for reducing readmissions. In the fall of 2022, the team engaged frontline staff, providers and patients to describe their current process in discharging patients and what would be the ideal process focused on the patient that can reduce readmissions. They identified that there were a lot of projects and resources on improving these 30-day readmissions and needed to work and communicate together rather than work in silos. There was a need to identify Social Determinants of Health (SDOH), review Transitions Care Management (TCM) processes and implement Compassion Transition Huddles for complex discharges.

As a result, they implemented Social Determinants of Health (SDOH) on inpatient units and assessed which SDOH affects patients, increased Transition of Care Management (TCM), follow-up phone calls and scheduled appointments, created a process for Compassion Transition Huddles, and designed readmissions interview questions by nursing team. This resulted in the highest SDOH- Social Connections and Physical Mobility, 2022 TCM Follow up Call Schedule of 52% had increased to 83% in 2024, TCM Appointment Schedule 2022- 48% increased to 67% in 2024, and readmissions rate was 9.8%. In addition, November 2024 Readmissions rate decreased to 5.49% and the goal was met and overachieved with a 40% improvement in decreasing readmissions.

Pressure injuries (PI) are one of the most common and costly complications occurring in healthcare organizations today. Throughout 2023, Bellin Health saw 19 serious reportable hospital-acquired pressure injuries (HAPI).

Currently, the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators benchmark for PI rate, per 1,000 admissions is 0.65. Bellin Health was higher than the AHRQ benchmark in 2023 at 1.2. The lack of a consistent and standardized approach regarding preventive interventions increased the patient’s risk of developing HAPI when admitted for an acute illness. Reduce serious reportable pressure injuries from 19 to 12 in FY2024 by developing a pressure injury prevention (PIP) bundle to standardize and structure preventative interventions and practices. As a system for fiscal year 23-24’, serious reportable pressure injuries decreased by 63.2% from 19 to 7, established a baseline for total all cause HAPI, fiscal year 24-25’ targets, All Cause <30 and serious reportable events less than 6. and Serious Reportable <6. The Agency for Healthcare Research and Quality (AHRQ) set the benchmark for pressure injury rates per 1,000 admissions at 0.65. In 2023 the organization had a pressure injury rate of 1.2, double AHRQ’s benchmark. In September of 2023, the organization developed a multi-disciplinary governance to combat hospital-acquired pressure injuries (HAPI). Throughout 2023, through the root cause analysis process, the team identified an opportunity to develop an evidence-based standardized bundle to decrease the incidents of HAPIs.

While considered preventable, approximately 2.5 million patients develop HAPI yearly. HAPIs increase the patient's risk of readmissions, length of stay (LOS), and associated complications and decreases organization reimbursement and overall quality of care. Implementing a pressure injury prevention bundle provides standardization and structure to promote positive patient outcomes with the use of evidence-based interventions. Currently this fiscal year, Bellin health is on track to meet the target of six or less serious reportable hospital-acquired pressure injuries. Throughout quarters one and two, the organization has reported only two serious reportable pressure injuries, and it has been over 100 days since last. Onboarding and continuing education will be the focus for this year as well as spreading pressure injury awareness and prevention to specialty areas such as the emergency department and surgical/procedural areas.