March 2022
July 18, 2023

Collaboration Reduces Hospital Readmissions, Improves Patient Care and Outcomes

The Health Quality Innovation Network team, a Centers for Medicare & Medicaid Services Hospital Quality Improvement Contractor, partners with health care providers in Kansas, Missouri, South Carolina and Virginia to support their quality improvement efforts. This includes spreading best practices to help other facilities achieve similar successes. One such provider, SoutheastHEALTH in Missouri, was recognized with a 2021 Health Quality Innovator of the Year award for the positive impacts they are making for patients in their region.

SoutheastHEALTH Callout boxAs part of their efforts to reduce readmissions, SoutheastHEALTH leans heavily on strong collaborations – both within and outside of the organizational family. Following are just a few initiatives that have improved patient care and outcomes:

  • Focusing on multi-visit patients, those with four or more acute care encounters within 12 months, SoutheastHEALTH identified the need for a palliative care program to support chronic disease management. The team prioritized educating patients and families on managing chronic disease and its symptoms.

  • Recognizing a gap in communication between acute care and post-acute care facilities, SoutheastHEALTH invited skilled nursing facilities from three surrounding counties to come together to share needs and issues. The collaboration identified gaps in care transitions and reinforced the facilities’ efforts to keep patient needs at the forefront.

  • Capturing social determinants of health and their impact on readmissions, SoutheastHEALTH identified a need to address food insecurities. They engaged their local food bank in discussions to develop an in-house post-acute care food pantry. In addition to offering short-term help to patients facing this issue, the team also connects them with local programs for ongoing assistance.

  • Identifying the importance and benefit of engaging the patient and/or family to understand post-discharge care goals, SoutheastHEALTH implemented motivational interviewing for patients at risk for readmission. Information gleaned from the interviews was used to determine perceptions of the issues that brought patients back to the hospital, goals following discharge, and issues or barriers that may prevent them from post-acute care follow up. Besides providing crucial information, the interviews foster a relationship between facility staff, patients and families.

These collaborations have had positive results on patients, from a 48.87 percent reduction in the number of discharges of multi-visit patients to a 17.8 percent reduction in all-cause readmissions between the collaborating skilled nursing facilities. The palliative care program, which started with one provider and the referral of 25 patients, has grown to four providers and 245 patients.

Southeast Health data points

The SoutheastHEALTH team has made great strides in improving patient care and outcomes related to chronic disease management, readmissions and social determinants of health issues in their local community.

For all of the positive impacts the team has made, SoutheastHEALTH received a 2021 Health Quality Innovator of the Year award. Read more about them and the other award winners.

Submitted by: Health Quality Innovation Network


This material was prepared by The Bizzell Group (Bizzell), the Data Validation and Administrative (DVA) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW/Bizzell/DVA-1151-07/18/2023

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