Preventing Readmissions for Patients with Chronic Illness

For patients with chronic diseases, day-to-day management of their conditions is key to staying healthy and out of the hospital. By addressing patients’ at-home care management as a routine part of hospital care, Yale New Haven Health System reduced 30-day readmissions by more than 31%, and Mount Sinai Medical Center reduced those readmissions by 43%.

At YNHHS, preventing readmissions starts with getting an accurate picture of the medications a patient is taking at home. Pharmacy techs at YNHHS use reports in Epic to find admitted patients with chronic conditions such as COPD, and then visit the patients to ask about their current medication regimens. A pharmacist uses Epic to recommend medication adjustments for the admission.

At Mount Sinai, a social worker uses predictions calculated by machine learning models in Epic to evaluate a patient’s risk of readmission. The social worker can enroll the patient in a transitional care management program to address specific psychosocial needs documented in Epic, such as at-home support and transportation to appointments.

Mount Sinai received a HIMSS Davies Enterprise Award for successes including their transitional care management program. Epic community members can access the Clinical Program featuring Mount Sinai, YNHHS, and members of the Epic Nursing Collaborative on the UserWeb and have Epic staff install it as part of Epic’s Services.